Acsm Physical Activity and Exercise

ACSM’s
Behavioral Aspects of
Physical Activity
and Exercise
2
ACSM’s
Behavioral Aspects of
Physical Activity
and Exercise
EDITOR
Claudio R. Nigg, PhD

Director: Health Behavior Change Research Workgroup
Department of Public Health Sciences, John A. Burns School of Medicine
University of Hawaii at Manoa
Honolulu, Hawaii
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ACSM Publication Committee Chair: Walter R. Thompson, PhD, FACSM, FAACVPR
ACSM Group Publisher: Katie Feltman
Umbrella Editor: Jonathan K. Ehrman, PhD, FACSM
Copyright © 2014 American College of Sports Medicine
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means,
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9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
ACSM’s behavioral aspects of physical activity and exercise / editor, Claudio R. Nigg.
p. ; cm.
Behavioral aspects of physical activity and exercise
Includes bibliographical references and index.
E-ISBN 978-1-4511-3211-3 (alk. paper)
I. Nigg, Claudio R., editor of compilation. II. American College of Sports Medicine,
issuing body. III. Title: Behavioral aspects of physical activity and exercise.
[DNLM: 1. Exercise—psychology. 2. Health Behavior. 3. Motivation.
4. Patient Compliance—psychology. QT 255]
RA781
613.7’1—dc23
2013012305
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make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application
of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and
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To my daughter, Zoe Nigg — You make it all worthwhile.
5
Preface
Our understanding of why people change their physical activity has grown substantially in the past century.
But much less is written or known about how people change their physical activity, or what people do or use to
become physically active on a regular basis. (If physical activity were available as a pill, it would be the most
often prescribed pill!)
ACSM’s Behavioral Aspects of Physical Activity and Exercise was written to fill this gap for the practitioner and
student alike. For practitioners, the book provides information for use in the field for trying to motivate
individuals to become more active. For students, the text shows how to change and promote physical activity.
Whether you are a practitioner or a student, you will find useful the tools, tricks, techniques, how-to’s, and
strategies for the promotion of physical activity provided by our expert authors.
ORGANIZATIONAL PHILOSOPHY
The book is organized as follows:
First, Chapter 1 provides a theoretical foundation — the leading theories of physical activity behavior
change, in the belief that practical applications are based on good theories.
Second, Chapter 2 addresses the idea that we cannot change what we cannot measure by providing know-
how to assess the relevant aspects of physical activity (i.e., what you need to know about the people you are
trying to motivate).
Third, the main body of the book addresses how to change physical activity behavior. These chapters
contain the majority of the tools, tricks, techniques, how-to’s, and strategies that you can use to help people
get active and stay active. This part of the book covers a broad range of topics, from how you can help clients
acquire the necessary skills (Chapter 3), to addressing how ready the client is (Chapter 4), to how to
communicate with the client (Chapter 5), to delivering physical activity messages using different media
(Chapter 6).
Fourth, we provide the broader picture. This includes chapters about how to influence the environment and
policy to help motivate people (Chapter 7), how to approach different populations (Chapter 8), and how to
practically evaluate physical activity programs (Chapter 9).
Finally, the last chapter (Chapter 10) focuses on the practical applications of professional skills, behaviors,
and other factors that can facilitate or impede behavior change.
FEATURES
The book is intended to be engaging, easily applied, and useful in your efforts to help people become more
physically active. To this end, most of the chapters include each of the following features:
• Concept Overview briefly sets the stage for the chapter.
• From the Practical Toolbox sections contain forms, checklists, charts, worksheets, and other resources that
can be used immediately. (A collection of all the tools in the book is available on the book’s companion
Web site; see the “Additional Resources” section that follows for more information.)
• Evidence sections include explanations of the latest research that support concrete recommendations.
• Step-by-Step applications are specific, user-friendly instructions that explain client-motivation techniques.
• Case Scenarios emphasize real-world application of the material.
• Take-Home Messages highlight the most important parts of the chapter.
In addition, for those of you who are instructors, several resources are included on the book’s companion
Web site, such as a Brownstone test generator, PowerPoint presentations, an image bank, and Learning
Management System cartridges. See the “Additional Resources” section that follows for more information.
All the people involved in this project sincerely hope that it will help you to help people become physically
active. Thank you for what you do and enjoy the book.
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ACKNOWLEDGMENTS
I would like to thank the following people for their valuable contributions, without which this book would not
have happened: the chapter authors for buying into this approach and writing to make a difference; Katie
Amato and Ashley Tsumoto for editorial support for the chapters; Angie Chastain for keeping me organized
(and on top of e-mails); Amanda Whittal for her support in copyediting Chapter 2; and the ACSM and
Wolters Kluwer editorial team for their professionalism and their expertise. Finally, I would like to
acknowledge ACSM for their vision in asking me to put this book together.
Claudio R. Nigg, PhD

Editor
ADDITIONAL RESOURCES
ACSM’s Behavioral Aspects of Physical Activity and Exercise includes additional resources for both instructors
and students that are available on the book’s companion Web site at http://thepoint.lww.com/ACSMBehav.
Instructors
Approved adopting instructors will be given access to the following additional resources:
• Brownstone test generator
• PowerPoint presentations
• Image bank
• Learning Management System cartridges
Students
Students who have purchased ACSM’s Behavioral Aspects of Physical Activity and Exercise have access to the
following additional resources:
• A collection of all the practical tools in the book, such as forms, checklists, charts, worksheets, and other
resources
In addition, purchasers of the text can access the searchable full text on-line by going to the ACSM’s
Behavioral Aspects of Physical Activity and Exercise Web site at http://thePoint.lww.com/ACSMBehav. See the
inside front cover of this text for more details, including the passcode you will need to gain access to the Web
site.
7
Contributors
Kacie Allen, BS
Virginia Tech
Blacksburg, Virginia
Chapter 9: Evaluating Physical Activity Behavior Change Programs and Practices
Adrian Bauman, MD, MPH, PhD

University of Sydney
Sydney, New South Wales, Australia
Chapter 7: Influencing Policy and Environments to Promote Physical Activity Behavior Change
Ute Bültmann, PhD

University Medical Center Groningen
Groningen, The Netherlands
Chapter 2: Assessing Your Client’s Physical Activity Behavior, Motivation, and Individual Resources
Lauren Capozzi, BSc

University of Calgary
Alberta, Canada
Chapter 8: Promoting Physical Activity Behavior Change: Population Considerations
Brian Cook, PhD

University of Kentucky
Lexington, Kentucky
Chapter 4: Building Motivation: How Ready Are You?
S. Nicole Culos-Reed, PhD

University of Calgary
Alberta, Canada
Chapter 8: Promoting Physical Activity Behavior Change: Population Considerations
Danielle Symons Downs, PhD

The Pennsylvania State University
State College, Pennsylvania
Chapter 1: Why Do People Change Physical Activity Behavior?
Paul Estabrooks, PhD

Virginia Tech
Carol Ewing Garber, PhD, ACSM-PD, ACSM-RCEP, ACSM-HFS

Columbia University
New York, New York
Chapter 10: Professional Practice and Practical Tips for the Application of Behavioral Strategies for the Physical
Activity Practitioner
Klaus Gebel, PhD

8
Heather Hausenblas, PhD
Jackson University
Jacksonville, Florida
Eric Hekler, PhD

Arizona State University
Phoenix, Arizona
Chapter 6: How to Deliver Physical Activity Messages
Sara Johnson, PhD

Pro-Change Behavior Systems, Inc.
West Kingston, Rhode Island
Chapter 4: Building Motivation: How Ready Are You?
Julia Kolodziejczyk, MS
San Diego State University
University of California, San Diego
Kristina Kowalski, BSc, MSc, PhD(c)

University of Victoria
British Columbia, Canada
Chapter 3: Building Skills to Promote Physical Activity
Blake Krippendorf, BS
Virginia Tech
Sonia Lippke, PhD

Jacobs University
Bremen, Germany
Chapter 2: Assessing your Client’s Physical Activity Behavior, Motivation, and Individual Resources
Rona Macniven, MSc, BSc

Greg Norman, PhD

University of California - San Diego
San Diego, California
Serena Parks, PhD

Virginia Tech
Heather Patrick, PhD

National Cancer Institute, National Institutes of Health
Bethesda, Maryland
Chapter 5: Communication Skills to Elicit Physical Activity Behavior Change: How to Talk to the Client
Kimberly Perez, MA, ACSM-HFS

Focus Personal Training Institute
New York, New York
Chapter 10: Professional Practice and Practical Tips for the Application of Behavioral Strategies for the Physical
9
Activity Practitioner
Ernesto Ramirez, MS
University of California - San Diego
San Diego, California
Erica Rauff, MS
The Pennsylvania State University
State College, Pennsylvania
Ken Resnicow, PhD

University of Michigan
Ann Arbor, Michigan
Ryan Rhodes, PhD

University of Victoria
British Columbia, Canada
Chapter 3: Building Skills to Promote Physical Activity
Erin Smith, MA
Virginia Tech
Pedro J. Teixeira, PhD

Technical University of Lisbon
Cruz Quebrada, Portugal
Claudia Voelcker-Rehage, PhD

Jacobs University
Bremen, Germany
Chapter 2: Assessing your Client’s Physical Activity Behavior, Motivation, and Individual Resources
Geoffrey Williams, MD, PhD

University of Rochester
Rochester, New York
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Reviewers
Sherry Barkley, PhD, ACSM-RCEP

Augustana College
Sioux Falls, South Dakota
Beth Bock, PhD

Brown University and the Miriam Hospital
Providence, Rhode Island
Cynthia M. Castro, PhD

Stanford University
Stanford, California
Nickles I. Chittester, PhD

Concordia University Texas
Austin, Texas
Joseph T. Ciccolo, PhD

Columbia University
New York, New York
Bhibha M. Das, PhD, MPH

University of Georgia
Athens, Georgia
Kelliann K. Davis, PhD, ACSM-CES

University of Pittsburgh
Pittsburgh, Pennsylvania
Rebecca Ellis, PhD

Georgia State University
Atlanta, Georgia
Christy Greenleaf, PhD, ACSM/NPAS-PAPHS

University of Wisconsin - Milwaukee
Milwaukee, Wisconsin
Katie M. Heinrich, PhD

Kansas State University
Manhattan, Kansas
Patricia J. Jordan, PhD

Pacific Health Research and Education Institute
Honolulu, Hawaii
Mary Ann Kluge, PhD

University of Colorado - Colorado Springs
Colorado Springs, Colorado
Emily Mailey, PhD

Kansas State University
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Manhattan, Kansas
Kathleen A. Martin Ginis, PhD

McMasters University
Hamilton, Ontario
Kristen McAlexander, PhD

Southern Methodist University
Dallas, Texas
Melissa Moore, PhD

Victoria University
Melbourne, Australia
Charles F. Morgan, PhD

University of Hawaii at Manoa
Honolulu, Hawaii
Terra Murray, PhD

Athabasca University
Athabasca, Canada
Neville Owen, PhD

Baker IDI Heart and Diabetes Institute
Ron Plotnikoff, PhD

University of Newcastle
Newcastle, Australia
Sarah Pomp, PhD

Free University of Berlin
Berlin, Germany
Deborah Riebe, PhD, FACSM, ACSM-HFS

University of Rhode Island
Kingston, Rhode Island
Carrie Safron, MA
Teachers College, Columbia University
New York, New York
David Seigneur, MS, ACSM-CES, FAACVPR

UPMC Mercy
Pittsburgh, Pennsylvania
Sarah A. Slattery, MA
Columbia University
New York, New York
John C. Spence, PhD

University of Alberta
Alberta, Canada
Takemi Sugiyama, PhD

Baker IDI Heart and Diabetes Institute
Sara Wilcox, PhD, FACSM

University of South Carolina
12
Columbia, South Carolina
Catherine B. Woods, PhD

Dublin City University
Dublin, Ireland
Julie A. Wright, PhD

University of Massachusetts
Amherst, Massachusetts
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Contents
Preface
Contributors
Reviewers
CHAPTER 1 Why Do People Change Physical Activity Behavior?
CHAPTER 2 Assessing Your Client’s Physical Activity Behavior, Motivation, and Individual Resources
CHAPTER 3 Building Skills to Promote Physical Activity
CHAPTER 4 Building Motivation: How Ready Are You?
CHAPTER 5 Communication Skills to Elicit Physical Activity Behavior Change: How to Talk to the
Client
CHAPTER 6 How to Deliver Physical Activity Messages
CHAPTER 7 Influencing Policy and Environments to Promote Physical Activity Behavior Change
CHAPTER 8 Promoting Physical Activity Behavior Change: Population Considerations
CHAPTER 9 Evaluating Physical Activity Behavior Change Programs and Practices
CHAPTER 10 Professional Practice and Practical Tips for the Application of Behavioral Strategies for the
Physical Activity Practitioner
Index
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UNDERSTANDING THE PRINCIPLES OF BEHAVIOR CHANGE
WHAT IS BEHAVIOR?
Behavior is broadly defined as anything an organism or living being does, which includes actions, words,
and manifestations of emotions and thoughts (17). Behavior must be observable, measurable, and
operationally defined in order to determine how to modify or change it. Behaviors have important
antecedents (cues or triggers that stimulate the behavior), as well as consequences (the positive and/or
negative outcomes that follow the behavior). However, behavior is operationally defined differently
across contexts. For example, physical activity behavior is often defined as a bodily movement, produced
by skeletal muscles, that uses more energy than when a person is at rest (67). Physical activity has also
been conceptualized as the “umbrella term” that includes several dimensions such as exercise, sport,
leisure activities, dance, etc. (14). However, people generally also view physical activity as a behavior that
is more like a habit, particularly when a person is regularly physically active. On the other hand, exercise
is often defined as a behavior that is a planned and uses structured movement of the body that is
designed with the goal of enhancing physical fitness (6). As a practitioner, you need to define the target
behavior first before developing a plan for behavior change. Elements of behavior change are presented
in more detail in the next section.
15
Behavior Change
Changing behavior is difficult. Why? Because people are creatures of habit and the things they do are the
behaviors they really want to do. These are the actions that “work best” or “are easy to do.” So to
conceptualize behavior change, you need to understand that many behaviors, particularly physical activity and
its related health behaviors, fall on a continuum from an undesired or health-risk behavior to a desired or
healthy behavior. Changing an undesired or health-risk behavior involves making a conscious decision to
repeatedly do something new or different or “not doing” something bad such as smoking or drinking excessive
alcohol. Similarly, changing a desired behavior such as being physically active or eating healthy involves the
same conscious decisions to repeatedly do the new behavior, until over time it becomes part of your regular
routine. So why then is it so difficult to make positive behavior changes? Because it is common nature to
actively seek out activities that you enjoy and avoid activities that you dislike. Unfortunately, many positive
health behaviors involve doing things you may not “like.” For example, although physical activity has
numerous health benefits, it also requires time, effort, and energy; thus, you need to make a conscious decision
to incorporate it into everyday life. Understanding the principles of reinforcement will further emphasize this
idea.
Principles of Reinforcement
“The way positive reinforcement is carried out is more important than the amount.” (BF Skinner)
Reinforcement is anything that increases the probability that a behavior will occur again, and the use of
rewards and punishments will increase or decrease the likelihood of a similar response happening in the
future. Skinner (62) argued that teaching rests entirely on the principles of reinforcement. Today, these
principles are among the most widely accepted and practiced in psychology and are the foundation for
changing behavior. The most basic assumption of reinforcement is if doing something results in a good
consequence (being praised or rewarded), a person will try to repeat the behavior, whereas if doing something
results in a bad consequence (being criticized or punished), a person will usually try not to repeat the behavior.
For example, if you start jogging and within a few weeks, you see a friend who says “Wow, that jogging is
really paying off. You look fantastic!” you will likely try to repeat the behavior in the future to receive more
positive praise from friends and family. In contrast, if you receive negative feedback from an important other
such as a family member who says “That running is only going to cause you to hurt yourself; I don’t know why
you even bother” you may stop jogging altogether in an effort to avoid this type of shame and criticism.
However, reinforcement in the “real world” is not always this straightforward. The same reinforcer may affect
people differently. For example, some people are motivated when a fitness instructor says “Come on, you need
to work harder! You’re just relaxing back there!” But other people may view this as negative feedback and stop
the activity altogether. The reinforcer needs to be tailored to the individual for it to be effective, particularly
when the behavior is as complex as physical activity. Thus, it is extremely important to understand the
individual and the value he or she places on different reinforcers. What works for one person may not work
for another!
The general consensus from most behaviorists is that the positive approach to reinforcement is most
appropriate because it increases the likelihood that desirable behaviors will be repeated in the future. From a
practical perspective, a positive approach to reinforcement also has a greater chance of strengthening
important determinants of physical activity such as attitude, motivation, and self-efficacy. While there is not
one set of guidelines for using positive reinforcement, researchers in the sport and exercise psychology domain
(71) have recommended the following strategies for using positive reinforcement for behavior change:
• Choose effective rewards: Rewards should be important and relevant to the person who is doing the
behavior. That is, you should like the reward, otherwise it will not be effective! Some of these rewards
may be intrinsic, such as you taking pride in your accomplishment or working harder to learn more and
perform better. Some of these rewards may be extrinsic, such as social (praise, public acknowledgement,
clapping), material (clothing, trophies, certificates of achievement), and/or monetary (cash or gift cards)
incentives.
• Schedule reinforcers effectively: Researchers (42,58,71) have demonstrated that continuous and
immediate reinforcement is desirable when a behavior is new or the person is in the early stages of
learning the behavior. Reinforcement should be immediate to maximize the likelihood of making a link
or connection between the desired behavior and a positive response. However, once the behavior has
become more routine, intermittent (sporadic or not expected) reinforcement is preferred because the
reinforcement otherwise becomes monotonous and loses its impact or value.
16
• Reward appropriate behaviors: As with scheduling reinforcers effectively, it is also important to be
selective about the behaviors that are rewarded. If you get rewarded for every behavior you do, the
impact of the reward structure is lost. Thus, you should know which are the most important behaviors
or outcomes to reward for a target person and when to consider rewarding close approximations to this
behavior. This is called shaping, which is when behaviors that are close to the desired behavior are
rewarded in an effort to gradually change an existing behavior over time (50,62).
• Reward performance and effort; not just the outcome: Similar to the goal-setting literature, it is
important to reward process or procedural determinants of behavior such as hard work, effort, and
dedication in addition to the actual performance or behavior. This will increase the likelihood you are
able to repeat the behavior in the face of adversity or barriers because you learn the value of the process
and will be less likely to give up when it is challenging to achieve the behavior.
• Positive motivational climate: Using positive reinforcers within a positive and supportive environment
can maximize the likelihood of behavior change. Feedback on the behavior should be given with
instruction and encouragement, patience, and an opportunity for discussion and additional feedback
with the target person or group.
However, behavior change is frequently determined by more than the principles of reinforcement. Thus, it is
important to consider theories that incorporate a more comprehensive approach to behavior change. The
following sections will provide an overview of why using theories and models to guide behavior change is
important and will also describe several frequently used behavioral theories to explain and predict physical
activity behaviors. Case example illustrations are also included to demonstrate how to apply these theories.
THEORIES OF BEHAVIOR CHANGE
The Importance of Theories and Models

“There is nothing more practical than a good theory.” (Lewin, K. (1952). Field theory in social science: Selected
theoretical papers by Kurt Lewin. London: Tavistock.)
Theories and models of behavior change can at first seem overwhelming to understand. However, once the
initial sense of apprehension for using theory passes, a practitioner often quickly sees the underlying value and
added benefits of using a theoretical approach. A simple way to view a theory or model is to see it as a
structured logical explanation or way of describing a certain phenomenon. A theory allows you to understand,
explain, and predict behavior. They provide the “how and/or why” a behavior occurs and offer an empirically-
based framework or “blueprint” from which to develop interventions to promote healthy behaviors such as
physical activity. A model provides a visual representation of a phenomenon—or an illustration of how certain
parts, known as the components, are related within a structure (10). Many theories have models but not all
models are based on a theory. From a practical perspective, a good theory often uses a model to demonstrate
how the components of the theory are related and predict behavior. Health promotion experts may choose to
use theories and/or models for many different reasons, including to better explain the factors that facilitate or
inhibit behavior change at the individual, community, and societal levels and/or to guide the selection and
development of appropriate health promotion strategies. It is important to note that theories should never be
applied without a good understanding of the “big picture”—that is, without a thorough insight and awareness
of the individuals, groups, organizations, and communities you are working with to promote healthy behavior
changes. Remember, a theory isn’t the solution, but rather the foundation.
To change or promote physical activity behavior, it is important to recognize the critical elements of the
most commonly used, evidence-based theories and models of behavior change. To this end, this section
provides an overview of several widely used theories/models applied to physical activity behavior, reviews
evidence from the literature with summaries of the research in the physical activity domain, offers a step-by-
step description of how to use the theory in practice, and presents example scenarios for illustration.
SELF-EFFICACY THEORY
WHAT IT IS AND WHY IT WORKS
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Self-efficacy is a person’s situation-specific belief in his or her capabilities to perform a behavior (7,8).
Whether you realize it or not, self-efficacy influences just about every choice you make—from deciding
to drive a car on a freeway to choosing to walk or jog today. Self-efficacy beliefs determine how you
think, feel, and behave (7). A belief that you have the capability to successfully carry out any or all of the
activities that you have thought about today will influence your decision to do or not do these actions.
Also, the amount of effort you invest in these activities will be influenced by the value of the belief. If
you have a weak belief in your personal capability to carry out a behavior successfully (i.e., low self-
efficacy), you will be uncertain and likely not invest much effort. On the other hand, if you have a strong
belief in your ability to do a specific task (i.e., high self-efficacy), you will undertake it with confidence
and conviction. A strong sense of efficacy enhances personal well-being and facilitates motivation and
effort. Higher assurances in your personal abilities also lead you to approach difficult tasks as challenges
to be mastered rather than threats to be avoided (7).
Self-efficacy is an integrated component of Social Cognitive Theory (8) and stems from the
assumption of Social Learning Theory (46) that if you are motivated to learn a behavior, the behavior
would be learned by observation and reinforced with positive reinforcement. Self-efficacy is thought to
be influenced by several main sources (see Figure 1.1). The first and most important source is mastery
(performance) experience. When you successfully carry out a task, you believe that you have the
capabilities necessary to repeat the behavior. Past successes have the most important influence on self-
efficacy and confidence in doing a behavior in the future. However, self-efficacy is fragile and therefore,
your past failures can also undermine your efficacy beliefs.
Another source of self-efficacy is vicarious experience or observational learning. The behaviors of
others (both successes and failures) can influence your self-efficacy. That is, observing a friend or family
member achieve success on a similar task can increase self-efficacy, whereas watching him/her fail in a
similar circumstance can diminish it.
A third but weaker source of self-efficacy is verbal persuasion. When you receive verbal praises such as
“Great job!” or “Keep going. You can do it!” from important others (friends, family members,
coaches/trainers), these praises generally have an immediate increase in efficacy beliefs. In contrast,
negative comments can damage or weaken efficacy beliefs—particularly under circumstances when there
is already doubt about your abilities. Generally, verbal persuasion has its greatest impact on self-efficacy
if you have some reason to believe that you could be successful if you persist.
Your physiological state can also impact self-efficacy. Factors such as rapid heart rate, elevated
respiratory rate, and increased sweating can provide a signal or cue to you about your current level of
self-efficacy. Your appraisal of the situation and these physiological cues is critical. When you are calm
and confident, these physiological cues are generally interpreted as being a part of the activity and are
usually in control. In contrast, if you interpret these physical signals as evidence of not being prepared,
they can serve to undermine efficacy and make you question your abilities.
A final source, emotional (mood) states, influences self-efficacy because of the association between your
past successes and failures and the moods associated with these events. When you are successful, these
experiences are stored in memory along with positive feelings (e.g., accomplishment, pride) that are
associated with the event. However, failed experiences are also stored in memory and linked with
negative feelings (e.g., frustration, shame). Mood states before a future event can trigger events from
memory and thus, the presence of a positive mood state prior to an action can prime memories of
accomplishment and joy and thereby serve to improve self-efficacy.
Because self-efficacy is a situation-specific construct, different operational definitions have evolved
over time. The following concepts are aspects of self-efficacy that have evolved in the research (45) as
key factors related to physical activity behaviors:
• Exercise efficacy: Beliefs about your ability to successfully engage in incremental bouts of physical
activity—varying across mode, intensity, and duration of the activity.
• Barriers efficacy: Belief about overcoming obstacles or barriers to physical activity participation.
Barriers can be social (lack of spousal support), personal (lack of motivation, feeling lazy), and/or
environmental (bad weather, unsafe neighborhood).
• Scheduling efficacy: Confidence in your ability to plan physical activity behaviors into a daily or
weekly routine.
• Health-behavior efficacy: Beliefs about your capability to engage in health-promoting behaviors such
as meeting the physical activity guidelines.
18
EVIDENCE
As mentioned earlier, the strongest source of self-efficacy is mastery (performance) experiences. It is thus not
surprising that the relationship between self-efficacy and physical activity participation is reciprocal. That is,
efficacy beliefs are associated with the initiation and maintenance of physical activity and in turn, short- and
long-term physical activity participation leads to significant increases in self-efficacy (44). Studies have
confirmed the important role of self-efficacy for exercise promotion. For example, a review of 27 self-efficacy
and exercise studies revealed a positive relationship between self-efficacy and exercise participation, and
specifically among intervention studies, participation in an exercise program promoted exercise self-efficacy
beliefs (35). The positive effects of self-efficacy on exercise participation appear to extend across a variety of
populations including cardiac rehabilitation patients (64), people with developmental disabilities (11),
adolescents with elevated diabetes and obesity risk factors (22), cancer survivors (47), and new mothers (23).
Although there is an abundance of evidence that improving self-efficacy beliefs can promote physical activity
behaviors, the important question is “How?” The next section provides a step-by-step description of how to
apply self-efficacy theory to promote physical activity behaviors.
FIGURE 1.1. The Self-Efficacy Theory. (Adapted with permission from Bandura A. Social foundations of thought and action. Englewood Cliffs
(NJ): Prentice Hall: 1986.)
STEP-BY-STEP: HOW TO APPLY SELF-EFFICACY THEORY TO PHYSICAL

ACTIVITY BEHAVIORS
Edward McAuley (43), an authority on the correlates of self-efficacy in physical activity, stated: “It is vitally
important for practitioners and programs to provide experiences that maximize individuals’ beliefs in their
sense of personal capabilities with respect to exercise and physical activity. If practitioners fail to [do so],
participants are likely to perceive the activity negatively, become disenchanted and discouraged, and
discontinue.” Thus, he proposed a series of strategies within each of the main sources to promote self-efficacy:
Step 1: Mastery Experiences

Set up the opportunity for mastery experiences by increasing the frequency of positive physical activity
experiences. For example, gradually increase the frequency and intensity of the activity—do not start out with
the maximum dosage from the start (e.g., a max fitness test); integrate activities of daily life that provide a
sense of accomplishment such as walking to work, taking the stairs instead of the elevator, and parking the car
farther from the store; find activities that people enjoy and maximize their chances of engaging in these
activities (e.g., joining a community facility, identifying an exercise buddy).
Step 2: Vicarious Experiences

Maximize the exposure to positive modeling experiences. For example, showing videotapes of successful
models of similar age, gender, physical characteristics, and capabilities; providing frequent participation in
modeling or expert demonstrations to learn the activity form, improve the sense of comfort or ease with the
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activity, and repeat the actions; and facilitating group activities in a supportive and cooperative environment to
increase peer-to-peer modeling.
Step 3: Verbal Persuasion

Augment opportunities for feedback with positive and encouraging feedback. For example, developing social
support networks and “buddy systems” to provide multiple opportunities for encouragement, providing a
telephone number for a contact person to provide emotional support and assist with overcoming barriers,
tapping into social media (e.g., Facebook, Twitter, online support groups), and using video/audio tape
recordings or Internet podcasts of positive feedback received from supportive others (personnel, family,
friends).
Step 4: Physiological States

Facilitate learning experiences to understand and interpret physical symptoms. For example, teach people how
to accurately and positively infer symptoms such as heart rate, respiratory rate, perspiration, muscle soreness,
weight changes, and general fatigue; explain how these symptoms are also positive cues for effective exercise
participation.
Step 5: Emotional States

Increase opportunities to discuss emotions and maximize opportunities for positive emotional states prior to
exercise participation. For example, provide supportive communication about feelings, thoughts, and moods as
they relate to physical activity participation; use strategies such as positive imagery and muscle relaxation to
promote feelings of calmness, control, and happiness prior to physical activity participation; assist a person
with “making the connection” between positive mood states and positive physical activity experiences (i.e.,
feeling better before exercise leads to feeling better during and after exercise).
Case Scenario 1.1
Intellistudies/Shutterstock.com
Julie is entering her senior year of high school and about to begin preseason for her last year of high
school soccer. Julie has been the team’s star midfielder leading the team in goals and helping carry the
team to the state playoffs. Julie is optimistic about the team this year; however, she is lacking the self-
efficacy to perform well due to an anterior cruciate ligament (ACL) tear that occurred during the winter
indoor soccer season. She was forced to have surgery to repair the ACL and missed out on the rest of
her indoor soccer season and all of the elite spring traveling team that she usually played on due to the
rehab therapy she was required to do. She is afraid that if she puts forth all of her efforts as she has done
in the past, she might re-tear her ACL since the doctor told her that re-tears are more likely after an
initial tear. She is also worried that the knee brace she must wear will inhibit her range of motion and
that she won’t be able to perform at the level she once did. She has dreams of playing collegiate soccer
but fears these things might ruin her goal of playing soccer in college.
In order to help Julie, a practitioner should consider the following strategies:
1. Past performance accomplishments: Have Julie make a list of her accomplishments (particularly
those she has achieved in the sport of soccer) and also include the barriers and challenges she
experienced along the way so she can relate to those times and remember how she handled those
challenges and what she did to overcome them.
2. Vicarious experiences: Show Julie pictures of videos of other elite athletes with a former ACL repair
surgery so she can see that it is possible to still perform well after surgery.
3. Verbal persuasion: Enlist the help of her family, teammates, and coaches to provide a positive and
supportive environment for her so she continues to gain confidence. These individuals should not
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focus on the fact that she is just recovering from a serious injury (i.e., “Wow, you’re really playing
great considering the injury you just had” or her coach going easier on her due to her injury), but
rather, they should treat her the same as before so that she doesn’t feel isolated as a result of her
injury.
4. Physiological and affective states: Julie needs to be taught to learn to listen to her body. She needs to
start slowly. If her knee starts to feel sore, she may need to reduce her training or cut back on
intensity or duration. The more in tune she is with her body, the less likely she will be to reinjure
herself. She also should maximize opportunities for positive mood states prior to her training (e.g.,
listening to music to get her excited, using imagery to visualize doing the activities correctly as she
rehabilitates her knee, etc.).
TAKE-HOME MESSAGES
Self-efficacy is a powerful belief that you are capable of organizing and executing the behavior that is
needed to produce a specific outcome. Self-efficacy is influenced by a variety of factors that include
mastery (performance) experiences, vicarious experiences, verbal persuasion, physiological states, and
emotional states. Specific to physical activity behaviors, self-efficacy plays an important role. When you
are more efficacious, you are more likely to sustain motivation, participation, and adherence, and you
are also more likely to report more positive and less negative effects after physical activity participation.
As a result, you also enjoy physical activity more! Finally, efficacy beliefs are driven by the individual;
therefore, understanding your sources of efficacy is essential for promoting positive efficacy beliefs.
TRANSTHEORETICAL MODEL
Note: This theory is presented here for chapter completeness. A more comprehensive approach for using this theory is
presented in Chapter 4.

For most people, changing unhealthy behaviors (e.g., physically inactive) to healthy behaviors (e.g.,
physically active) is often challenging. Change usually does not occur all at once; it is a lengthy process
that involves progressing through several stages. At each stage, your cognitions and behaviors are
different, and so one approach to facilitating behavioral change is not appropriate. The concept of stages
—or a “one size does not fit all” philosophy (39)—forms the basis for the Transtheoretical Model
(TTM) of behavior change developed by James Prochaska and his colleagues (53). This model emerged
from a comparative analysis of leading theories of psychotherapy and behavior change (56). The TTM
includes the following four constructs:
1. stages of change
2. decisional balance
3. processes of change
4. self-efficacy
Each of these constructs is described briefly below and in detail in Chapter 4.
STAGES OF CHANGE
Stages of Change recognizes that behavior change unfolds slowly over time through a series of stages.
Prochaska and DiClemente (54) hypothesized that as you change from an unhealthy to a healthy behavior—
for example, from a sedentary to an active lifestyle—you move through a number of stages at varying rates and
in a cyclical fashion with periods of progression and relapse. If you are sedentary, you may begin to think
about the benefits (e.g., more energy) and costs (e.g., time away from watching television) of physical activity.
Then, a few months later, you may buy a pair of walking shoes. Six months later, you may start walking 3
times a week. After a year of walking, however, you may become overwhelmed with the stress of work and
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stop it altogether. The cessation of physical activity would represent a regression to an earlier stage (i.e.,
relapse). In short, as you go through the process of behavioral change, you typically cycle, or progress and
relapse, as you recognize the need to change, contemplate making a change, make the change, and finally,
sustain the new behavior. There are five main stages through which you pass in attempting any health
behavior change: precontemplation, contemplation, preparation, action, and maintenance (57). Figure 1.2
provides a graphic illustration of the stages of change. A brief description of each stage is provided next. For a
more comprehensive description, see Chapter 4.
Precontemplation (“I won’t or I can’t”)
If you are in the precontemplation stage, you are either not considering or do not want to change your
behavior. The so-called “couch potato” is an example of someone who would fall into the precontemplation
stage for physical activity. As adopting physical activity is concerned, you may be in precontemplation because
you do not think it’s valuable, or think it’s valuable but may be overwhelmed by barriers such as lack of time.
Precontemplators are the most difficult people to stimulate into behavioral change. They often think that
change is not even a possibility.
FIGURE 1.2. The Stages of Change Model.
Contemplation (“I might”)
If you are in the contemplation stage, you acknowledge that you have a problem (e.g., “I know I need to be
more physically active”) and are thinking about changing your behavior sometime within the next 6 months.
You see a need for change because you are aware of the costs and benefits of changing your behavior (55).
Preparation (“I will”)
In the preparation stage, you are planning to change your activity level in the near future, usually within the
next month. Preparation is an unstable stage because when you are in this stage, you are more likely than
precontemplators or contemplators to progress over the next 6 months (55).
Action (“I am”)
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When you have recently changed your behavior (i.e., within the last 6 months), you are in the action stage.
This is the stage that requires the greatest commitment of time and energy. Because you have just recently
established the new habit, attentiveness is necessary to avoid relapse (i.e., reduce or stopping physical activity).
Maintenance (“I have”)
Once you have been regularly active for 6 consecutive months, you are deemed to have made it to the
maintenance stage. Although the new behavior has become better established, boredom and a loss of focus
can become a danger for inactivity. It is at this time that you work to reinforce the gains made through the
various stages of change and strive to prevent a relapse.
DECISIONAL BALANCE
Decisional balance assesses the importance that you place on the potential advantages or pros and
disadvantages or cons of a behavior (31). The balance between the pros and cons varies depending on which
stage of change you are in. When the cons of exercise (e.g., takes time away from other activities) are of greater
importance than the pros of exercise (e.g., improves psychological well-being), motivation to change behavior
(i.e., move from being sedentary to engaging in physical activity) is low. Thus, for example, in the
precontemplation and contemplation stages, the cons are assumed to outweigh the pros. In the preparation
stage, the pros and cons are believed to be relatively equal. Finally, in the action and maintenance stages, the
pros are thought to outweigh the cons.
PROCESSES OF CHANGE
Processes of Change are the 10 processes of change that represent the behaviors, cognitions, and emotions
that people engage in to change a behavior. They are defined in more detail in Chapter 4 and include:
• Consciousness Raising (gathering information)
• Counterconditioning (making substitutions)
• Dramatic Relief (being moved emotionally)
• Environmental Reevaluation (being a role model)
• Helping Relationships (getting social support)
• Reinforcement Management (being rewarded)
• Self-Liberation (making a commitment)
• Self-Reevaluation (developing a healthy self-image)
• Social-Liberation (taking advantage of social mores)
• Stimulus Control (using cues)
FIGURE 1.3. The Self-Determination Theory. (Adapted with permission from Deci EL, Ryan, RM. Intrinsic Motivation and Self-
Determination in Human Behavior. New York: Plenum Publishing Co: 1985.)
Self-efficacy, as previously mentioned in this chapter, is a judgment regarding your ability to perform a
behavior required to achieve a certain outcome. Not surprisingly, it is critical to behavior change (8) and has
been incorporated into the TTM. According to the TTM, self-efficacy is proposed to change with each stage,
presumably increasing as you gain confidence, through for example, successful attempts to increase physical
activity. Conversely, self-efficacy may decrease if you falter and spiral back to an earlier stage. See Figure 1.3
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for a graphical display of the TTM constructs.
EVIDENCE
The TTM was first applied to physical activity in the late 1980s by Sonstroem (63) and since then its
popularity has grown dramatically. Marshall and Biddle (41) conducted a meta-analysis of 91 independent
samples from 71 published studies that examined at least one of the aforementioned constructs of the TTM
applied to physical activity. They found the processes of change, self-efficacy, and decisional balance differed
across the stages in the direction predicted by the model. They also noted that stage membership is associated
with different levels of physical activity, self-efficacy, pros and cons, and processes of change. More recently,
Hutchinson, Breckson, and Johnston (30) reviewed the TTM-based interventions for physical activity
behavior change and found that most of the interventions failed to accurately represent all dimensions of the
model. They concluded that to examine efficacy of the model, practitioners should develop physical activity
interventions that accurately represent all the TTM model constructs (i.e., stages of change, self-efficacy,
decisional balance, and processes of change).
STEP-BY-STEP: HOW TO APPLY THE TRANSTHEORETICAL MODEL TO

PHYSICAL ACTIVITY BEHAVIORS
To successfully apply the TTM to physical activity, you must first determine the person’s stage of change. See
From the Practical Toolbox 1.1 for a stage of change questionnaire that you can use to determine a person’s
stage of change. Once you know a person’s stage of change you can then target the remaining TTM
constructs (i.e., the process of change, self-efficacy, and decisional balance; see From the Practical Toolbox 1.2
through 1.4 for questionnaires that assess these TTM constructs) in an attempt to change physical activity
intentions and/or behavior, with the ultimate goal of moving a person forward along the stage of change
continuum.
For decisional balance, you can tell if people are moving forward through the stages by looking for
differences in the number of pros versus cons they list for exercise. For example, in the precontemplation
stage, the cons of exercising will far outweigh the pros. Carlos DiClemente and his colleagues (25) noted that
assessing the pros and cons is relevant for understanding and predicting transitions among the first three
stages of change (i.e., precontemplation, contemplation, and preparation). During the action and maintenance
stages, however, these decisional balance measures are much less important predictors of progress.
From the Practical Toolbox 1.1
EXAMPLE OF A STAGES OF CHANGE QUESTIONNAIRE

For Exercise
The following five statements will assess how much you currently exercise in your leisure time
(exercise done outside of a job). Regular exercise is any planned physical activity (e.g., brisk walking,
jogging, bicycling, swimming, line-dancing, tennis etc.) performed to increase physical fitness. Such
activity should be performed three or more times per week for 20 or more minutes per session at a level
that increases your breathing rate and causes you to break a sweat (6).
Do you exercise regularly according to the definition above? Please mark only ONE of the five
statements.
1. _____ No, and I do not intend to begin exercising regularly in the next 6 months.
2. _____ No, but I intend to begin exercising regularly in the next 6 months.
3. _____ No, but I intend to begin exercising regularly in the next 30 days.
4. _____ Yes, I have been, but for less than 6 months.
5. _____ Yes, I have been for 6 months or more.
SCORING
Item 1=Precontemplation; Item 2=Contemplation; Item 3=Preparation; Item 4=Action; Item
5=Maintenance
For Physical Activity
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The following five statements will assess how much you currently engage in regular physical activity
in your leisure time. For physical activity to be regular it must be done for 30 minutes (or more) per
day, and be done at least 5 days per week (67). For example, you could take three 10-minute brisk
walks or ride a bicycle for 30 minutes. Physical activity includes such activities as walking briskly,
biking, swimming, line dancing, and aerobics classes or any other activities where the exertion is
similar to these activities. Your heart rate and/or breathing should increase, but there is no need to
exhaust yourself.
Do you regularly engage in physical activity according to the definition above? Please mark only
ONE of the five statements.
1. _____ No, and I do not intend to begin regularly engaging in physical activity in the next 6
months.
2. _____ No, but I intend to begin regularly engaging in physical activity in the next 6 months.
3. _____ No, but I intend to begin regularly engaging in physical activity in the next 30 days.
4. _____ Yes, I have been, but for less than 6 months.
5. _____ Yes, I have been for 6 months or more.
SCORING
Item 1=Precontemplation; Item 2=Contemplation; Item 3=Preparation; Item 4=Action; Item
5=Maintenance
Questionnaire for exercise: Reprinted with permission from the following source; questionnaire for physical activity: Adapted with permission
from the following source: Nigg CR and Riebe D. The Transtheoretical Model: Research review of exercise behavior and older adults. In:
Burbank P and Riebe D, editors. Promoting Exercise and Behavior Change in Older Adults: Interventions with the Transtheoretical Model. Springer
Publishing Company; 2002, p. 147–80.
PROCESSES OF CHANGE SCALE

The following experiences can affect the exercise habits of some people. Think of similar experiences
you may be currently having or have had during the past month. Then rate how frequently the event
occurs by circling the appropriate number. Please answer using the following 5-point scale:
25
SCORING
Consciousness Raising – 1, 11, 21
Dramatic Relief – 2, 12, 22
Environmental Reevaluation – 3, 13, 23
Self-Reevaluation – 4, 14, 24
Social Liberation – 5, 15, 25
Counterconditioning – 6, 16, 26
Helping Relationships – 7, 17, 27
Reinforcement Management – 8, 18, 28
Self-Liberation – 9, 19, 29
Stimulus Control – 10, 20, 30
Reprinted with permission from Nigg CR and Riebe D. The Transtheoretical Model: Research review of exercise behavior and older adults. In:
26
For self-efficacy, remember that your self-efficacy for exercise will increase as you progress along the stage of
change continuum. Please refer to the section early on step-by-step procedures for targeting self-efficacy to
give people the confidence that they can make and maintain changes in their exercise behavior.
Finally, the process of change enables you to understand how shifts in intentions and behavior occur. As
previously mentioned, there are 10 processes of change that represent the behaviors, cognitions, and emotions
that you engage in during the course of changing behavior. To progress through the early stages (i.e.,
precontemplation, contemplation, and preparation), you apply cognitive, affective, and evaluative processes.
As you move toward maintenance, you rely more on commitments, conditioning, contingencies,
environmental controls, and support. Different strategies are most effective at different stages of change. For
example, counterconditioning and stimulus control can really help you in the action and maintenance stages.
But these processes are not helpful for someone who is not intending to take action. As another example,
consciousness-raising and dramatic relief work better for someone in this stage than in the precontemplation
stage.
SELF-EFFICACY/CONFIDENCE SCALE
This part looks at how confident you are to exercise when other things get in the way. Read the
following items and fill in the circle that best expresses how each item relates to you in your leisure
time. Please answer using the following 5-point scale:
I am confident I can participate in regular exercise when:
SCORING
All 6 items are a general self-efficacy scale representing the six factors. The long form (3 items per
factor) may be obtained from the editor.
FIGURE 1.4. The Theory of Planned Behavior. (Adapted with permission from Ajzen I. The theory of planned behavior. Organ Behav Hum
Decis Process. 1991;50:179–211.)
See Figure 1.4 for a representation of how the TTM constructs work to change people’s intentions and
behavior.
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DECISIONAL BALANCE SCALE

This section looks at positive and negative aspects of exercise. Read the following items and indicate
how important each statement is with respect to your decision to exercise or not to exercise in your
leisure time by filling in the appropriate circle. Please answer using the following 5-point scale:
SCORING
PROS – 1, 3, 5, 7, 9
CONS – 2, 4, 6, 8, 10
Case Scenario 1.2
berna namoglu/Shutterstock.com
Carla is a 60-year-old couch potato who is overweight. Her doctor recently diagnosed her as prediabetic
and has encouraged her to start exercising. She denies having a problem and has no intention of making
a change in her physical activity in the next 6 months. Carla also has a lack of motivation to become
physically active and has many “excuses” for not being physically active. She does not think that physical
activity is valuable in being able to help her lose her excess weight and other related health issues. She
feels overwhelmed by barriers such as lack of time and lack of knowledge on how to be physically active,
and she strongly feels that being physically active is impossible for her.
To help Carla, a practitioner should consider the following:
• Stage of change: First, determine the stage of change Carla is in. Because Carla has no intention of
beginning an exercise program in the foreseeable future, she is in the precontemplation stage.
Knowing her stage of change will enable a practitioner to develop a physical activity intervention that
is tailored to that person’s stage of change. .
• Decisional balance: Have Carla list her pros and cons of exercising. You want to make her more
aware of the multiple benefits of changing from a sedentary to an active lifestyle. Emphasize the pros
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of exercising over the cons.
• Processes of change: Use the processes of change of dramatic relief, consciousness raising, and
helping relationships to move Carla from the precontemplation to the contemplation stage. In order
to do this, you can help Carla gather information about the health benefits of being physically active
and how it can help her lose weight and reduce her likelihood of developing diabetes (i.e.,
consciousness raising). You can also have Carla express her feelings about being sedentary and
overweight. Finally, have Carla assess how her inactivity affects her friends and family. For example,
Carla is not able to actively play with her grandchildren because she does not have the energy to do
so. Also, she is not able to go for nightly walks with her husband. Educating Carla about her
inactivity is critical in helping her to start thinking about becoming more active.
TAKE-HOME MESSAGES
Over the past few decades, the TTM has been increasingly applied to examine physical activity
behavior. The core constructs of the TTM are the stages of change, processes of change, decisional
balance, and self-efficacy.
The most frequently examined construct of the TTM in the physical activity domain has been the
stages of change construct. The stages of change assesses your progression and regression through five
main stages as you attempt to become physically active: precontemplation (not intending to make
changes), contemplation (intending to make changes in the foreseeable future), preparation (immediate
intention to change), action (actively engaging in the new behavior), and maintenance (sustaining
change over time).
The processes of change are the overt and covert activities that individuals use to alter their
experiences and environments to modify behavior change. Decisional balance focuses on the benefits
(pros) and costs (cons) of a behavior, and is thought to be important in the decision-making process.
Finally, self-efficacy is a judgment regarding one’s ability to perform a behavior required to achieve a
certain outcome. It is important to apply all the applicable TTM constructs (i.e., processes of change,
self-efficacy, decisional balance) when attempting to change people’s physical activity motivation and
behavior.
SELF-DETERMINATION THEORY
Note: This theory is presented here for chapter completeness. A more comprehensive approach for using this theory is
presented in Chapter 5.

Self-Determination Theory (SDT) (24) is a practical theory that was developed to explain affective,
cognitive, and behavioral responses in an achievement domain (i.e., an area that you can set goals to
strive for, particularly in terms of competence relevant activities such as academics) and it can be applied
to physical activity to understand your motives. SDT is based on the concept that you have three
primary psychological needs:
• The need for competence (i.e., ability to effectively perform a behavior)
• The need for relatedness (i.e., social connections with others)
• The need for autonomy (i.e., independence to make own decisions)
As a result, you seek challenges to satisfy at least one of these three basic needs. SDT also suggests that
three types of motivation drive your behaviors (see Figure 1.3):
• Amotivation: On one end of the continuum, amotivation is the absence of motivation. In terms of
exercise behavior, you may show amotivation toward being physically active for a number of
reasons, such as a lack of self-discipline to fit exercise into your daily routine or the belief that
exercise is not necessary and will not result in a desired outcome (i.e., weight loss).
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• Extrinsic motivation: Next on the continuum is extrinsic motivation, which is often viewed
negatively and is not an ideal means of motivating you to perform specific behaviors. However, in
terms of exercise behavior, it is important to note that being extrinsically motivated to be physically
active is not necessarily a bad thing since exercising to lose weight and improve your health are
technically considered to be extrinsic motives, but they are great reasons for you to be physically
active. Deci and Ryan (24) described four types of extrinsic motivation:
• External regulation: The least self-determined of these four, this is the process of performing a
behavior because of an external reward (i.e., exercising to receive praise from others or monetary
compensation) or to avoid punishment (i.e., exercising to avoid being scolded by a significant
other).
• Introjected regulation: Describes behavior that is contingent on self-imposed pressures such as
exercising to avoid feelings of guilt.
• Identified regulation: Is a more autonomous form of extrinsic motivation driven by your personal
goals (i.e., exercising to lose weight or running to train for a 5k).
• Integrated regulation: Is the most self-determined type of extrinsic motivation that includes
engaging in a behavior to confirm your sense of self (i.e., I am a cyclist or a runner and this is
what I do). However, integrated regulation is still considered extrinsic because the goals you are
trying to achieve are for reasons extrinsic to yourself, rather than the inherent enjoyment or
interest in the task.
• Intrinsic motivation: Is engaging in a behavior for reasons of pleasure, enjoyment, and fun.
SDT examines predictors of physical activity including factors in the environment (i.e., rewards,
positive feedback), within the person (i.e., basic psychological needs), and allows for the examination of
important psychological outcomes as a result of the physical activity (i.e., perceived competence) (28).
SDT provides useful guidelines for practitioners to use for targeting how to motivate people for physical
activity.
EVIDENCE
Much of the initial research using SDT within the physical activity domain has been cor-relational in nature
(18). Correlational designs are important for identifying the antecedents of physical activity behavior and the
underlying mechanisms that are associated with these antecedents, but such designs are limiting. Therefore,
experimental designs are needed to establish causality.
There are limited experimental and interventional studies applying SDT within a physical activity context.
Most of the early work was focused on the sports domain (20,21,69); but recently researchers have focused on
experimental methods that examine specific constructs of SDT and their effects on exercise behavior.
Researchers have demonstrated that manipulations designed at changing self-determined motivation resulted
in changes in exercise intentions that furthermore resulted in changes in exercise behavior (19). There have
also been recent advances in the development of interventions in applied settings using SDT to increase
motivation for physical activity in students (26,70), promote leisure physical activity in sedentary young adults
(48), understand physical activity motives in cancer survivors (49) and increase physical activity in overweight
women (59–61).
Despite these recent successes, there is still a need for further research examining the role of autonomy-
supportive techniques to change self-determined motivation and physical activity behavior (e.g., providing
participants with options about intensity, frequency, and type of exercise-related activities; praising
participants for improvements in techniques and fitness). Researchers and practitioners should teach these
strategies to individuals so they have the tools to engage in physical activity behavior on their own after the
intervention has ended. Future research is also needed to better understand the underlying mechanisms that
are not only important for initial behavior change, but for long-term adherence to physical activity behavior.
STEP-BY-STEP: HOW TO APPLY SELF-DETERMINATION THEORY TO

PHYSICAL ACTIVITY BEHAVIORS
To effectively use SDT to promote physical activity behavior and adherence, Kilpatrick and colleagues (36)
developed the following set of guidelines for practitioners:
30
Step 1: Provide Choice of Activities to Promote Autonomy
Make a conscious effort to involve people in the decision-making process to promote both autonomy and self-
determination. For example, giving a person the ability to choose the type of physical activity they enjoy most
will promote autonomy while also increasing enjoyment. These are essential steps in “hooking” a person on
engaging in physical activity. Also, providing multiple activities to choose from is more likely to lead to
increased independence rather than forcing people to do one activity without any other options.
Step 2: Provide a Rationale for Activities

Explain why a person is engaging in physical activity, how the activity has health benefits, and which aspects
of fitness will improve as a result of the physical activity. Giving someone a rationale and purpose not only
creates a sense of autonomy, but it is also likely to lead to positive perceptions of the activity, which is more
likely to foster the development of intrinsic motivation.
Step 3: Provide Positive Feedback so Individuals Gain a Sense of Competence

Positive feedback includes praise as well as constructive criticism for improving a behavior. The type of
feedback will vary depending on their skill level. For instance, a highly skilled and experienced exerciser may
perceive corrective or instructional feedback as more helpful than positive reinforcement, while a novice
exerciser may respond favorably to praise and encouragement. Positive feedback has been shown to foster
confidence and competence, which in turn will lead to greater enjoyment of the activity and stronger intrinsic
motivation.
Step 4: Promote Process Goals That Are Moderately Difficult

Process goals focus on the tasks necessary to achieve goals—that is, the specific steps for successfully
performing a behavior. Practitioners should create an environment based on competence rather than
competition against others and encourage individuals to measure their success relative to their own
performances rather than comparing to others. Also, setting moderately difficult goals are likely to result in
short-term success that can foster competence. If the goals are too difficult, failure may be more likely to
occur, which will lead to decreased confidence and motivation for that behavior.
Step 5: Promote the development of social relationships

Adherence is more likely to occur when people build social connections, which in turn leads to greater
satisfaction and increases the likelihood of long-term physical activity maintenance.
Case Scenario 1.3
vseb/Shutterstock.com
INTROJECTED REGULATION
Susie is in her mid 40s. She has been exercising irregularly for the past year (i.e., goes to the gym 4 or 5
days a week for a month and then not again for another 3 months). Her main motivation for going to
the gym or going out for a run is to improve her appearance for different events such as a friend’s
wedding or a party with friends. She is exhibiting extrinsic motives for being physically active driven by
a need to look aesthetically better when she has to see friends or family. As a result, Susie is not
adhering to a regular exercise regimen or exercising for inherent pleasure or to improve her overall
health.
Susie would benefit from a program that requires her to set moderately difficult goals such as
exercising every week, 3 to 5 days a week and not quitting once she sees results that she wants. Susie
should pick the activities that she wants to do to promote autonomy and to make sure the activities she
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is engaging in are enjoyable for her. Also, Susie should set personal goals to achieve (i.e., run a 5k) so
that she can experience mastery of these tasks as well as feelings of pride and satisfaction (see From the
Practical Toolbox 1.5 for an example goal setting sheet). Finally, Susie should be encouraged to take
group fitness classes to promote relatedness and satisfy her need for social interactions.
GOAL SETTING AND SELF-DETERMINATION THEORY EXAMPLE
Case Scenario 1.4
Shutterstock.com
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AMOTIVATION
Justin was a high school football player who was previously in good physical shape due to team workouts
and weightlifting. However, once he entered college, his regular exercise routine stopped and he
continued this “no exercise” routine through his 20s. Justin does not see any reason to be physically
active now that he is no longer playing football. He lacks any form of discipline or motivation to go to
the gym on a regular basis. He knows that he is a few pounds overweight, but does not see any problem
with the extra pounds he has gained since high school. He believes he is perfectly healthy and has no
need to exercise.
To help Justin, there are several important things a practitioner or interventionist needs to consider.
They need to explain to Justin the importance of physical activity for his health. Since Justin is slightly
overweight, they should explain the consequences that are likely to occur if he continues to lead a
sedentary lifestyle (i.e., development of obesity, metabolic syndrome, heart disease). Justin has no
motivation to be physically active; therefore, the goal would be for him to eventually achieve intrinsic
motivation toward being active.
A program designed to encourage Justin to develop intrinsic motivation should be aimed at
enhancing his sense of competence and autonomy within a positive, supportive environment where
social interactions can take place. Justin should be able to choose the types of activities he wishes to
engage in so that he has a sense of ownership and control over his workout routine to enhance his sense
of autonomy toward exercise. Having choice in the type of activity he does will also make the activity
more enjoyable for Justin and increase the likelihood that he continues to be physically active. Also,
developing a program that allows Justin to feel successful in mastering his choice of activity will help to
develop his feelings of competence. Finally, group exercise may be beneficial in addition to exercising on
his own because it fulfills his sense of relatedness and will develop social support toward being active.
As a novice exerciser, Justin would start with simple, low-intensity activities that he can master and
thus develop feelings of satisfaction toward being active. It is likely that Justin will first experience
extrinsic rewards from being active (i.e., weight loss, improved mood) and hopefully continued exercise
behavior will be enjoyable and satisfying, such that Justin develops intrinsic motives for being active.
Also, over time, the duration and intensity of his exercise can be increased so that he continues to be
challenged and does not get bored with his exercise routine.
Therefore, incorporating all three basic needs (autonomy, competence, and relatedness) are important
so that Justin can move from being amotivated to being intrinsically motivated toward exercising.
However, it is important to note that it may not be necessary to target all three basic needs when
intervening with individuals as it may be too overwhelming for certain individuals. It is important to
tailor the intervention design to the individual and target the needs of that individual that will be the
most influential in helping them become more intrinsically motivated to be physically active.
TAKE-HOME MESSAGES
SDT specifies that individuals seek behaviors that satisfy three basic needs: competence, autonomy, and
relatedness. The theory furthermore indentifies three forms of motivation (amotivation, extrinsic
motivation, and intrinsic motivation) that drive individuals’ achievement behaviors. Following the
recommendations provided in this chapter to target individuals’ sense of autonomy and competence,
self-determination theory can be easily incorporated into practice to promote and encourage physical
activity.
Theory of Planned Behavior

The Theory of Planned Behavior (TPB) is a theory about the link between your attitudes and behaviors.
Ajzen (3) defined behavior in terms of a single action (taking an aerobics class), directed at a specified
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target (fitness center) in a given context (YMCA community center), and at a specified time (Tuesday
nights at 5pm) (27). Ajzen proposed the TPB as an extension of the Theory of Reasoned Action (5).
The TPB is one of the most predictive persuasion theories, and it has guided a large majority of the
physical activity theory–based research (3). This theory specifies that some or all of the following four
main psychological variables influence your behavior (see Figure 1.4):
• Intention: Intending to perform a behavior is the main determinant of whether or not you engage
in that behavior. Intention is reflected in your willingness and how much effort you are planning to
exert to perform the behavior. The stronger your intention to perform a behavior, the more likely
you will engage in that behavior. Thus, if you have a strong intent to go biking this afternoon, you
are more likely to do it. As might be expected, your intention can weaken over time. The longer
the time between intention and behavior, the greater the likelihood that unforeseen events will
produce changes in your intention. For example, you may intend to go for a long bike ride on the
weekend. However, bad weather may make it difficult to safely take a long ride, and thus, even
though you have a strong intent, you will not be able to go for a bike ride. Your intention, or level
of motivation, is influenced by your attitude about the behavior, the perceived social pressures to do
the behavior (i.e., subjective norm), and the amount of perceived control over performing the
behavior (i.e., perceived behavioral control). These are described in more detail in the following.
• Attitude: Is your positive or negative evaluation of performing a behavior. For example, an older
adult may have a negative attitude toward engaging in a vigorous physical activity such as running,
but have a positive attitude toward walking in the neighborhood. Your attitude toward a specific
behavior (whether it be walking or running for example) is a function of your behavioral beliefs,
which refer to the perceived consequences of carrying out a specific action and your evaluation of
each of these consequences. For example, your beliefs about playing doubles tennis could be
represented by both positive expectations (e.g., it will improve my social life because I will meet lots
of people) and negative expectations (e.g., it will reduce my time with family). In shaping a physical
activity behavior, you evaluate the consequences attached to each of these beliefs. Common
behavioral beliefs for physical activity are that it improves fitness/health, improves physical
appearance, is fun/enjoyable, increases social interactions, and improves psychological health (65).
• Subjective norm: Is your perceived social pressure to perform or not perform a particular behavior.
Subjective norm is from your normative beliefs, which are determined by the perceived expectations
of important significant others (e.g., family, friends, physician, priest) or groups (e.g., classmates,
teammates, church members) and by your motivation to comply with the expectations of these
important significant others. For example, a mother may feel that her pregnant daughter should
not exercise during her pregnancy. The daughter, however, may not be motivated to comply with
her mother’s expectations, and thus she walks regularly throughout her pregnancy.
• Perceived behavioral control: Represents your perceived ease or difficulty of performing a behavior.
You may hold positive attitudes toward a behavior and believe that important others would approve
of your behavior. However, you are not likely to form a strong intention to perform that behavior if
you believe you do not have the resources or opportunities to do so (27). For example, you may
have a positive attitude and enjoy swimming; however, if you do not have access to a pool, you will
not be able to perform this behavior. Perceived behavioral control is a function of control beliefs,
which represent the perceived presence or absence of required resources and opportunities (e.g.,
“there is a road race this weekend”), the anticipated obstacles or impediments to behavior (e.g., “the
probability of rain on the weekend is 95%”), and the perceived power of a control factor to facilitate
or inhibit performance of the behavior (e.g., “even if it rains this weekend, I can still participate in
the road race”) (4). The most common control beliefs for physical activity are lack of time, lack of
energy, and lack of motivation (65).
EVIDENCE
Several statistical reviews have supported the TPB for explaining and predicting a wide variety of physical
activities across many populations, such as ethnic minorities, youth, pregnant women, cancer patients, cancer
survivors, and older adults, just to name a few (5,12,29,33,34,66). In general, the research has found that
intention is the strongest determinant of your behavior, followed closely by perceived behavioral control. And
your intention to perform a behavior is largely influenced by your attitude and perceived behavioral control,
34
followed by the subjective norm. It is important to note though that the influence of each of the TPB
constructs can vary from population and context.
THEORY OF PLANNED BEHAVIOR BELIEF ITEMS

Instructions. The following questions relate to your walking behavior during cancer treatment. List
as many that apply to you in the space provided below.
List the main advantages of walking during your cancer treatment [behavioral beliefs]
List the main disadvantages of walking during your cancer treatment [behavioral beliefs]
List the main factors that prevented you from walking during your cancer treatment [control beliefs]
List the main factors that helped you in walking during your cancer treatment [control beliefs]
List the individuals or groups who were/are most important to you when you thought/think about
walking during your cancer treatment [normative beliefs]
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Source: http://people.umass.edu/aizen/tpb.html
STEP-BY-STEP: HOW TO APPLY THE TPB TO PHYSICAL ACTIVITY

A strength of the TPB is that an elicitation study forms the basis for developing questions to assess the TPB
constructs in a specific population. The elicitation study enables you to determine the specific beliefs for a
specific population. This is very important because beliefs vary by population and even by activity. For
example, the main behavioral beliefs for breast cancer survivors are that physical activity “gets my mind off
cancer and treatment, makes me feel better and improves my well-being, and helps me maintain a normal
lifestyle.” In comparison, the main behavior beliefs for pregnant women are that exercise “improves my mood
and reduces physical limitations common to pregnancy, such as nausea.” Because beliefs vary by population,
researchers and practitioners are strongly encouraged to refer to research that has already determined the
physical activity beliefs of your specific intervention population (e.g., postpartum women, cancer survivors,
high school students). If physical activity beliefs for a practitioner’s population of interest have not been
determined, then it is recommended that you conduct a pilot study (i.e., known as an elicitation study) to
determine the pertinent beliefs concerning a behavior for your specific population. Protocol suggested by
Ajzen and Fishbein (65) for conducting elicitation studies include:
• Using open-ended questions to determine the important behavioral, normative, and control beliefs in a
small sample of the targeted population (see From the Practical Toolbox 1.6);
• Carrying out a content analysis (i.e., a simple frequency count) to determine which beliefs are most
salient; and
• Developing structured items from the content analysis (see From the Practical Toolbox 1.7).
EXAMPLES OF THEORY OF PLANNED BEHAVIOR ITEMS

Note. These items are for pregnant women in their first trimester. Reword to reflect the population
you are studying.
Regular exercise behavior is participating in 30 minutes of accumulated moderate exercise on most, if
not all, days of the week. This exercise can be done at one time (e.g., 30 minutes of continuous
walking or jogging) or accumulated in the day (e.g., walking 10 minutes in the morning and 20
minutes in the evening). Examples of activities often done during pregnancy include walking, aqua-
aerobics, and low impact fitness classes.
In this survey, we are interested in your personal opinions regarding regular exercise during the first
three months of pregnancy (i.e., your first trimester). Although some of the questions may appear
very similar, each addresses a somewhat different issue. Please read each question carefully and reply
by circling the number that best reflects your opinion.
1. For me to exercise regularly during my first trimester will be:
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8. Most people who are important to me want me to exercise regularly during my first trimester.
9. Most women who are important to me have themselves exercised regularly during their first
trimester.
10. Most pregnant women will themselves exercise regularly during their first trimester.
11. Most people whose opinion I value think that I should exercise regularly during my first
trimester.
12. Most people I care about would approve of my exercising regularly during my first trimester.
13. My doctor or health care provider thinks that I should participate in regular exercise during my
first trimester.
14. I will exercise regularly during my first trimester.
15. Whether I exercise regularly during my first trimester is completely up to me.
37
16. Exercising regularly during my first trimester is under my control.
17. If I want to, I can easily exercise regularly during my first trimester.
18. I intend to exercise regularly during my first trimester.
19. I plan to exercise regularly during my first trimester.
20. My goal is to exercise regularly during my first trimester.
21. I exercised regularly during my first trimester.
22. I had the ability to exercising regularly during my first trimester.
23. For me to exercise regularly during my first trimester is:
24. I am determined to exercise regularly during my first trimester.
Theory of Planned Behavior Global Items Information

Attitude: Items 1, 2, 3, 4, 5, 6, and 7
Intention = Items 14, 18, 19, 20, 24
Subjective Norm: Items 8, 9, 10, 11, 12, and 13
Behavior = Item 21
Perceived Behavioral Control: Items 15, 16, 17, 22, and 23
Source: http://people.umass.edu/aizen/tpb.html
Ajzen and Fishbein (65) proposed that structured items that arise from the elicitation study should be
specific to the target at which the behavior is directed, the action or specificity of the behavior under study,
and the context and time in which the behavior is being performed. This means, for example, that when
trying to develop a walking intervention for older adults, you should ask a sample of older adults to: “list the
main advantages of walking briskly 3 times a week for 30 minutes outside during the summer.” This
information will help you develop an intervention based on the salient behavioral beliefs of these older adults
that is specific to the behavior. According to the TPB, once beliefs are modified, intention will be altered and
38
the desired behavior change will occur (4,66).
The relative contribution of the TPB constructs may fluctuate from context to context. Thus, before
interventions using this framework are implemented, the predictive ability of these constructs with the specific
population and specific context should first be tested.
The TPB is useful in identifying psychosocial determinants of physical activity, and thus it is useful for
developing community and individual exercise programs. For example, exercise programs that offer a positive
experience would obviously increase the intention to exercise, which in turn influences exercise behavior.
Positive behavioral beliefs and their evaluation may be enhanced if you are given experiences with enjoyable
types of physical activities and then are gradually encouraged to increase the intensity, duration, and frequency
of those activities. Perceived behavioral control is an important factor in the intention to be physically active
(13,51). When you perceive physical activity as difficult to do, intention is low. Overcoming barriers such as
lack of time, competing demands and other obligations, and feelings of inability should enhance perceptions
of control about carrying out physical activity. The next step in research using the TPB is to determine
whether belief-based programs will lead to increased levels of physical activity and to determine whether
beliefs about physical activity behavior change as one initiates and continues to engage in physical activity
behaviors (52).
Case Scenario 1.5
Diego Cervo/Shutterstock.com
Bill is a 75-year-old retired school teacher who lives alone and likes to garden and do yard work in the
summer months. This keeps him very active because he typically spends about two hours a day outside
doing various yard activities from mowing the grass to raking to picking weeds. However, during the
colder winter months, Bill tends to become sedentary and retreats to watching television to fill the time
that he normally spends doing yard work in the summer. Because of Bill’s advancing age and the fact
that he lives alone, his doctor is concerned that he is not active enough during the entire year. His
doctor wants Bill to maintain a more constant level of physical activity during all months of the year so
that he has a high level of functional physical activity to ensure that he can perform day-to-day activities
such as getting himself dressed, avoiding falling, and doing household chores.
To help Bill, a practitioner should consider the following:
• Behavioral beliefs: Have Bill make a list of activities that he may enjoy doing in the winter as well as
the summer.
• Normative beliefs: Have Bill establish some winter activities that he can do with friends, such as mall
walking. Have him identify friends and family that will support the types of activities he will be doing
and make sure they are aware of his goals so they can provide the perceived support he needs.
• Control beliefs: Provide Bill with a list of issues that may arise (such as bad weather) that may make
it difficult to be active in the winter, and then provide Bill with the skills to overcome these issues.
For example, if the weather is too cold or stormy to do activities outside, provide him with activities
that he can do inside (e.g., exercise videos, home exercise equipment).
• Intention: Provide him with a motivational plan for year-round activities.
TAKE-HOME MESSAGES
Changing your behavior is very difficult to do, especially when you are dealing with a complex health
behavior such as physical activity. To increase the success of predicting, understanding, explaining, and
changing physical activity behavior, researchers and practitioners should use a theoretical framework
39
such as the TPB as a guide (68). Researchers have found support for the utility of attitude, perceived
behavioral control, and to a lesser extent, subjective norm in explaining people’s intention to becoming
physically active. Also, research has found a strong relationship between your intention to be active and
whether you do the behavior. Furthermore, your perception of control over engaging in physical activity
can also directly predict behavior. In short, because of the success of the TPB for explaining and
predicting physical activity behavior, it offers you a useful framework to guide physical activity
interventions.
OTHER THEORIES TO CONSIDER

While a detailed overview of several, frequently used theories and models applied to physical activity behaviors
has been provided in this chapter, there are nonetheless other conceptual frameworks that have been used in
the exercise domain. While they have been used less frequently than other frameworks, these are important to
consider because to date there is no single “exercise theory” that consistently and effectively explains and
predicts exercise behavior. In the following, you will find a brief explanation of the Health Belief Model,
Relapse Prevention, and the Social Ecological Model.
THE HEALTH BELIEF MODEL

The Health Belief Model (HBM) (32) is one of the most widely recognized conceptual frameworks for health
behavior. The main hypothesis is that behavior depends on two conditions: (a) value placed by you on a
particular goal and (b) your estimate of the likelihood that a given action will achieve the goal (32). When
these two conditions are viewed within the context of health-related behaviors, the focus is either on the
desire to avoid illness (or if already ill, to get healthy) or the belief that a specific action will prevent or
improve illness. Thus, HBM is most useful as a framework when a chronic disease (e.g., cancer, diabetes,
cardiovascular disease) is imminent.
The first component of HBM is perceived susceptibility, or your belief that you are personally susceptible to a
particular illness (e.g., my chances of developing prostate cancer are high because it runs in the family).
Perceived severity is your opinion of the seriousness of a condition and its consequences (e.g., cancer is a serious
disease that can reduce my quality of life and if not effectively treated, can take my life).
The first four constructs of HBM represent your readiness to take action:
• Perceived benefits: Represents your opinion of the efficacy of the advised action to reduce risk or
seriousness of impact. For example, whether you believe that engaging in regular physical activity (e.g.,
30 minutes of moderate-intensity physical activity a day) can reduce your cancer risk.
• Perceived barriers: Are your perceptions of the physical and psychological costs of the advised action.
For example, you may believe that physical activity can reduce your cancer risk, but barriers such as
inexperience with physical activity, low motivation, lack of time, and physical discomfort (e.g., radiation
treatment causes soreness) may reduce or altogether prevent the likelihood that action takes place.
• Cues to action: These trigger your readiness to take action and stimulates the actual behavior. Examples
of Cues to Action include those that are personal (e.g., breathlessness when walking up stairs or a family
member or friend who becomes sick) as well as strategies that provide “how-to” information or
instructions on the behavior, promoting awareness about disease risks, and providing reminders or
prompts (e.g., phone calls, texts, notes) to initiate the behavior.
• Self-Efficacy: This recent addition to the model (for a full description of this construct, see the “Self-
Efficacy Theory” section earlier in this chapter), which represents your confidence in your ability to take
action. Strategies to increase self-efficacy include training/guided instruction, multiple opportunities for
success with the desired behavior, and verbal praise for positive reinforcement.
RELAPSE PREVENTION
Relapse prevention (40) is a cognitive-behavioral approach with the goal of identifying or preventing high-risk
situations. This model is most useful as a framework when setbacks (or relapses) are common, particularly
with high-risk behaviors such as substance or alcohol abuse, obsessive-compulsive behavior, and depression.
Typically these behaviors are high in frequency and undesired—thus, it may seem less applicable to apply this
framework to physical activity, which is a desired behavior, yet often of low frequency. Nevertheless, this
model can provide some insight regarding the antecedents of exercise cessation—when you reduce or stop
exercising altogether.
40
Marlatt and Gordon (40) identified three primary triggers of relapse (in the case of exercise, exercise
cessation):
• Personal conflict
• Negative emotional states
• Social pressures
In particular, negative emotional states (e.g., depression, anger, stress) and social pressures (e.g., increased
pressure from school or work colleagues to engage in activities other than exercise) are common predictors of
inactivity.
A key to preventing relapse is having effective coping strategies. When coping strategies are strong (e.g.,
self-awareness, optimistic outlook, supportive family/friends), self-efficacy is higher and you have a reduced
chance of relapse (exercise cessation). However, when coping strategies are poor or absent, self-efficacy is low
and attributions are negative (e.g., feelings of helplessness, lack of control), and in turn, relapse (or exercise
cessation) is likely. Therefore, understanding and identifying effective coping strategies is an effective way to
prevent exercise cessation.
THE SOCIAL ECOLOGICAL MODEL

The Social Ecological Model is a framework for understanding multiple levels of influence on behavior. It
emphasizes that the individual is responsible for engaging in healthy behaviors, but it also considers that
surrounding social and environmental pressures and manipulations are key determinants of taking action.
This approach has several adaptations. The most commonly used in the exercise domain is based on
Bronfenbrenner’s (15,16) Ecological Systems Theory which divides environmental factors into four main
influences. These factors can be illustrated as an “onion” (see Figure 1.5):
• The individual is at the center of this system.
• The next layer is the microsystem, or the immediate systems in which you interact (e.g., family, school,
work environments, parks, gyms, etc.).
FIGURE 1.5. The Social Ecological Model. (Adapted with permission from Bronfenbrenner U. Toward an experimental ecology of human
development. Am Psychol. 1977;32:513–31.)
• The mesosystem, which is the next level of influence, represents the interaction of multiple individual
systems. For example, the influences of parents (home microsystem) and teachers (school microsystem).
• The final two systems represent the most global or broader environmental influences. The exosystem
represents external systems such as school or community boards, and the macrosystem encompasses all
other systems (e.g., government, economic, social, etc.).
The closer the system is to the individual, the stronger the direct influence it has on that person’s behavior.
The Social Ecological Model is a useful framework for guiding physical activity behavior when the role of
the environment plays a key factor in the behavior change. For example, in order for a community to be able
41
to engage in active commuting such as biking or walking to work, there must be good access to bike/walking
paths, basic infrastructure to support it (e.g., sufficient sidewalk space, good flow of sidewalks and paths to
main locations, bike racks, etc.), and connectivity of rural and urban areas (e.g., rails to trails for longer
commutes vs. only highway access to main areas). Social ecological models have become more popular in
recent years as interest has increased in how the built environment may facilitate exercise initiation and
maintenance.
INCORPORATING THEORY-BASED TECHNIQUES AND PRINCIPLES INTO

PRACTICE
Now that the importance of theories and models has been established, and the theories have been explained,
the next step is to understand how to incorporate theory-based strategies and principles into practice.
Theories provide a logic model or roadmap for where to focus your efforts. They help to identify where to
start and how to navigate the journey.
The foundation of a logic model is identifying the behavioral antecedents—or factors that precede the
behavior—and then understanding how these antecedents influence the likelihood of a future behavior (37).
By identifying these important antecedents, you can determine key targets for intervention, and in turn
develop and implement more effective programs.
For example, in the Theory of Planned Behavior (1,4), one’s intention (level of motivation) is identified as a
primary determinant (behavioral antecedent) of behavior. The greater the level of motivation for physical
activity, the more likely a person will engage in physical activity behaviors. Thus, according to this theory, in
order to get people to be more physically active, you need to target their intention, or motivation, for the
behavior.
In the Self-Efficacy Theory (9), the most important source of self-efficacy, or your belief in your abilities, is
past performance accomplishments or experiencing mastery. When you successfully carry out a task, you will
believe that you have the capabilities necessary to engage in the behavior in the future. For example, if you
walk in a 5k event and successfully complete the race, you will have a greater belief that you can accomplish
another event like this in the future. Therefore, according to this theory, in order to help promote behavioral
change, you need to find ways of creating successful mastery experiences.
In the Health Belief Model (32), behavior depends upon several factors, including your perceived
susceptibility of getting a disease, perceived severity of the condition and its consequences, perceived benefits
of engaging in the behavior for reducing risk, perceived barriers or costs of doing the behavior, and your
confidence in your ability to take action and start the behavior. For example, if you are a sedentary person, you
may believe that you could have a heart attack (perceived susceptibility is likely), that inactivity can lead to a
heart attack (perceived severity is great), and that starting to engage in physical activity will reduce this risk
(perceived benefits) without causing negative side effects of excessive difficulty (low perceived barriers).
The point is that theories provide you with the basic starting foundation. It is important to note that no
single theory or model explains the broad scope of all health behaviors; or more specifically, explains 100% of
physical activity behavior. You need to take into consideration the target individual or audience,
environmental factors that may influence behavior, as well as other factors. In addition, a combination of
theories may provide the best explanation for variations in behavior (37).
TAKE-HOME MESSAGES
This chapter reviewed the basic principles of behavior change as well as provided an overview of several
theories and models that can provide you with a useful foundation to promote physical activity. While
there is not a single theory of physical activity behavior change, the most important aspect is choosing a
conceptual framework that provides a good understanding of the key factors that influence physical
activity behavior in the target population. After all, these antecedents (thoughts, beliefs, barriers, etc.)
are what provide us with clues about “the how and why” a behavior occurs (or doesn’t occur) in order to
initiate physical activity behavior change and sustain long-term maintenance.
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FURTHER WEB RESOURCES

The following Web site provides useful information on how to develop theory of planned behavior questionnaires and intervention:
http://people.umass.edu/aizen/tpb.html
The following Web site includes an extensive list of questionnaires used to assess constructs of Self-Determination Theory, with some
specifically in an exercise context (i.e., motives for physical activity):
http://www.psych.rochester.edu/SDT/questionnaires.php
44
INTRODUCTION: ASSESSING INDIVIDUALS’ PHYSICAL ACTIVITY AND
MOTIVATION
Most organizations, like the American College of Sports Medicine (ACSM), provide guidelines to perform
physical activity regularly (8). Specifically, the ACSM recommends to engage in…
• moderate-intensity cardiorespiratory exercise training for 30 minutes or more per day on 5 or more days
per week, or
• vigorous-intensity cardiorespiratory exercise training for 20 minutes or more per day on 3 or more days
per week, or
• a combination of moderate- and vigorous-intensity exercise to accumulate a total energy expenditure of
500–1000 or more MET minutes per week; and additionally
• resistance exercises for each of the major muscle groups a minimum of 2 days per week and
• neuromotor exercise (functional fitness training) involving balance, agility, and coordination for each of the
major muscle-tendon groups (a total of 60 seconds per exercise) a minimum of 2 days per week.
The activity can be performed in bouts of 10 minutes as part of daily living, or as part of a fitness program.
Although these guidelines are helpful, they also raise many practical questions (see Figure 2.1).
To best answer the questions found in Figure 2.1, we require an understanding of motivation and behavior,
as well as other individual variables such as needs, wishes, fears, and barriers to physical activity. Such
information can be acquired from those individuals whom we want to help. Different aspects or variables are
important to assess within a person. Besides these, it is inevitable that environmental characteristics, such as
45
the availability of proper facilities, also influence exercise behavior. Ecological frameworks, like the model by
Bronfenbrenner (6), describe different levels: individual, social, physical environment, and policy (Figure 2.2).
FIGURE 2.1. Practical questions arising from recommended physical activity guidelines.
FIGURE 2.2. Ecological model of physical activity.
This chapter will focus only on the two inner levels shown in Figure 2.2 (individual and social levels), as we
can directly assess how individuals perceive their environment, and what their expectations and (perceived)
barriers are. The two outer levels are important as well, and are presented in Chapter 7.
Step-by-Step
As professionals working with clients, we need information about our clients’ thoughts, expectations,
perceptions, and competencies regarding health behaviors to help them adequately. For doing so, a good way
is to determine:
1. The target population
2. The physical activity behavior of interest
3. Related behaviors of interest
4. Psychological and social (mediator/predictor) variables of interest
5. The measurement strategy
On the basis of this information, a measurement and assessment plan can be set up.
Case Scenario 2.1 demonstrates the practical application of the preceding steps when faced with the task of
helping people become and remain physically active. Such a scenario might occur in any environment in
which people work, learn, meet, or simply spend time.
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Case Scenario 2.1
CandyBox Images/Shutterstock.com
Consider a university with a relatively small and young campus, with 1,500 students and 450 faculty and
staff members (=target population). Currently, physical exercise programs exist for students and
employees. A recreation center hosts a rowing tank, gyms, and a well-equipped fitness facility. The wide
variety of fitness equipment includes cardiovascular equipment, free weights, and resistance training
machines. Additionally, a gymnasium provides athletic grounds and sports equipment, such as balls, nets,
and rowing equipment. The question is how many people are performing physical activities within the
physical exercise programs, in the recreation center and the gymnasium (= physical activity behavior of
interest).
In addition to changing rooms and bathroom facilities in the center, different buildings on campus
provide showers for those students and employees who cycle to the campus (=related behaviors of
interest).
A small interviewing (=measurement strategy) shows that (a) 30% of the university’s students and
employees engage in at least one physical exercise program once a week. It also reveals that (b) an
additional 25% of students and employees would be interested in using it (=psychological and social
variables). Finally, (c) the university board is not satisfied with the user numbers in the recreation center,
and seeks better utilization (=psychological and social variables).
For this scenario, we can apply questions exploring how to help individuals engage in and maintain
the recommended activity levels. How can we answer the question how to help individuals? There are
different approaches:
1. We can generate some solutions ourselves.
2. We can ask students, faculty, staff, alumni, and the public, or a representative sample of those parties,
what they desire, like and dislike.
3. We can look into the literature and previous good examples to search for theories and evidence to
base our own developments on.
A combination of all these approaches would certainly be the most favorable. However, to meet the
needs of the people, we must begin with understanding and assessing them.
If our aim is to understand individual and social factors, and design strategies that help to improve the
behavior of individuals, we require additional information. Only if we understand what people do (e.g.,
physical activity level), feel (e.g., perceived barriers to activity), and think (e.g., motivation), can we
adequately tailor our intervention to each individual. Moreover, assessment is equally important in order
to evaluate if our intervention was satisfactory and achieved desired outcomes.
In particular, describing how to measure aspects of an individual that affect health behavior is
imperative for the following chapters of this book, because it allows us to understand individuals and
their feelings, thoughts, and aims better. The goal of such measurements is to accurately assess the
behavior, needs and preconditions of the client, such as intention or self-efficacy. When this is achieved,
results of the assessment and measurement can be used for optimally designing and modifying health
interventions to each individual. Further, when we establish which aspects should be changed
throughout an intervention (such as intention), or what the outcome of an intervention should look like
(e.g., behavior change or behavior maintenance), interventions can be tailored adequately and evaluated
47
accordingly. In this chapter, we provide example assessment scenarios to display practical implications of
the information at the individual and social level. We also demonstrate possible tools or items that are
useful for assessment. These tools generally originate from validated questionnaires published in
research papers, and references to these studies are provided throughout the chapter. Furthermore, we
refer to useful Web-sources in which these assessment tools can also be found.
TAKE-HOME MESSAGES
Assessment opens avenues for understanding and addressing individuals’ behaviors, motivations, and
determinants of behavior. With the results from assessments, we are able to design appropriate
interventions and evaluate their effectiveness.
Assessment Modes
A health behavior is any behavior that improves health and well-being, which in turn helps to prevent the
onset or progression of morbidity, as well as premature mortality. Thus, physical activity can be a health
behavior if it is performed with appropriate intensity and frequency. Health behaviors also include risk
reduction behaviors, such as limiting sedentary activities like television watching. Although many people are
well aware that they should perform health behaviors on a regular basis, reports show that alarming numbers
of people are not meeting the physical activity recommendations (8). This is especially the case for those who
have disabilities and chronic illnesses.
To better cover different aspects of physical activity behavior, assessment of physical activity could cover the
different aspects displayed in Table 2.1.
As you can see, there is more than just the pure behavior in terms of movements an observer would see if he
or she monitors the individuals from the outside; psychological aspects such as easiness of execution are
important as well. That is, some components of a behavior can be obtained through observation and other
objective measures. However, not all facets can be observed or measured by means of physiological indicators,
so self-report measures are also used (18). The advantages and disadvantage of various assessment modes are
shown in Table 2.2.
Tools for Assessing Self-Reported Information

Self-reported information (questionnaires/interviews) is often used to measure physical activity and its
determinants. While physical activity can also be assessed by objective methods, such as observation or
physiological measures, influences like motivation are typically measured by self-reports. Although the validity
(degree to which measurement actually measures what it should measure) of self-reports of behavior is not
always assured, they are rather easy to obtain in comparison to objective measures.
The type of interview used can vary in usefulness, depending on the specific approach. Narrative and
unstructured interviews utilize methods in which little or no predefined questions are asked, and questions are
instead open ended (i.e., the interviewee can respond in a narrative text form, instead of in the form of “yes-
no” or multiple choice answers). These interviews often result in very different outcomes. This can complicate
the comparison of information from multiple interviews (e.g., of one person interviewed several times).
Alternatively, interviews can also be organized like questionnaires, providing well-defined question-and-
answer options. This restricts gathered information to a range of selected answers, making it easier to
compare. While the main difference between interviews and questionnaires is how the clients disclose
themselves, they each have distinct advantages, as well as some similar traits. An interviewer requires the
client to reveal all answers to the interviewer. In a questionnaire, however, the answering procedure is
anonymous, which may reduce social desirability bias. For example, social desirability bias may cause the client
to report more health behavior than they actually performed. Alternatively, interviews allow the interviewer to
clarify questions for the client; an advantage not as likely with questionnaires. The anxiety of sharing personal
information can occur in both questionnaires and interviews.
TABLE 2.1 Different Aspects of Behavior Assessment
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Aspect Example
Energy expenditure kcal, MET (metabolic equivalent)
Length of behavior time Time (minutes per week)
Frequency of behavior Number of times per week
Easiness of executing (intensity) How demanding it is to perform the intended activity
Note: For measuring and calculating MET (1, 7).
TABLE 2.2 Different Assessment Modes: Advantages and Disadvantages
Subjective Assessment Objective Measures

Content Perceived Value Outside Measures
Method Person is directly asked about his or her behavior Behavior is monitored with a device, like pedometer or
accelerometer (tracking steps or movements), or by direct
• Interviews, observation (attendance rates; observing which products are
• Questionnaires, or bought or used for exercising, etc.).
• Diary logs and self-monitoring strategies.
Advantage Individual resources and impediments such as Less likely to be biased by social desirability (tendency to present
intention, inner temptations, perceived self-efficacy oneself in a more favorable manner than is actually true) and
and perceived social support, can only be measured answering tendencies (e.g., to agree to questions)
subjectively.
Disadvantage Social desirability (to present oneself in a more Most are more challenging (time consuming, expensive) to gather.
positive view) affects validity and reliability of
measures.
Diary log techniques and self-monitoring strategies can be very similar to questionnaires. With these
techniques, clients are asked to monitor, say, the amount of their daily steps by carrying a pedometer and
entering the daily number it reads into a log. Such a log can be a hard-copy book or an electronic book
version. The latter provides the option to receive immediate feedback relating to the performed steps. For
example, individual/ipsative: “Today, you performed 7000 steps. That is two times more than yesterday.” Or
normative: “Today, you performed 7000 steps. That is less than the recommended 10,000 steps/day.”
TIME CONSIDERATIONS
When designing self-report surveys to assess information, several aspects are important to consider. First, the
nature of the behavior should be considered: Whether the behavior in question may consist of an action
performed on a single occasion, or a repeatedly performed action. For example, we might be interested in learning
whether a person participates in regular physical activity (which can be measured by means of the PAR-Q—
see the description later in this chapter and 22,23), or in a sports event (single occasion). The answer to either
of these can then only be dichotomous, providing a “yes” or “no” response. Physical exercise, however, has to
be performed repeatedly in order to be health promoting. Thus, we are now interested in a repeatedly
performed behavior.
Second, physical activity can be assessed over the course of a defined time span (e.g., “How often did you
exercise during the last month?”), or measured by questioning the typical quantity and frequency of the
behavior (e.g., “How often do you exercise during a typical week?”). Additionally, in the case of an accident or
some other health conditions preventing one from performing his or her typical activities, individuals should
receive a concrete instruction, such as thinking about the month prior to that incident. Any health incident
should be considered and taken into account when evaluating the information.
Third, the optimal period for measurement should be considered. The course of a defined time span should
be assessed if there are clear reasons for doing so. Defining a time span is recommended for the following
situations:
1. If behavior change process is expected to occur—for example, after an intervention,
2. If a special interval was predicted by social-cognitive variables at an earlier point in time, such as predicting
participation in a marathon half a year after measuring the intention to do so, or
3. If the individual has been in an unusual condition—for example, after a surgery or vacation.
49
Alternatively, having no time frame is sometimes advantageous, as specific time frames might be arbitrary:
Why should a person who intends to adopt a physical activity in 6 months and 1 day be different from a
person intending to start a physical activity in 5 months and 20 days or from a person intending to change
within 6 months? There is no empirical evidence for this specific cutoff of 5 months and 20 days or 6 months.
Contemporary assessments measure stages of change (see examples in Table 2.3) without using a specific time
frame (10, 11).
PRECISION OF MEASUREMENT
The precision of measurement must also be considered. The level of comprehensiveness of behavior can be
very broad (e.g., “I follow an active lifestyle”), or more precisely defined in terms of duration (e.g., “I bicycle to
work every day, which takes about 30 minutes”). In order to have precise measurements, questions are asked
about frequency and duration of exercising (e.g., “How many days per week did you perform sports activities?
How many hours and minutes did one session last?”). Alternatively, the answers can be given on rating scales
with verbal anchors (e.g., less than 1 time a month or never (1), 1–3 times a month (2), approximately once a week
(3), between 2 and 3 times a week (4), 4–5 times a week (5), and (almost) every day (6)). In order to rate
statements broadly, answers can be given on a rating scale that ranges from not at all (1) to exactly (6).
TABLE 2.3 Stages of Change Assessment
Instruction: Please think about your typical week. Did you engage in physical activity at least 5 days per week, for 30 minutes or more at a
time (or a total of 2.5 hours during the week), in such a way that you were moderately exhausted? From the following statements, please
choose the one that describes you most accurately by checking the number.
No, and I do not intend to start 1

No, but I am considering it 2
No, but I seriously intend to start 3
Yes, but it is rather difficult for me 4
Yes, and it is rather easy for me 5
Adapted with permission from Lippke S, Ziegelmann JP, Schwarzer R, and Velicer WF (2009). Validity of stage assessment in the adoption
and maintenance of physical activity and fruit and vegetable consumption. Health Psychology, 28(2), 183–193.
Objective Measures: Rationale, Tools, and Advantages

Some objective measures (such as steps performed during a week measured with a pedometer, and others as
shown in Table 2.4) typically have higher accuracy than subjective ones (measured by means of an interview).
This is because individuals do not have to respond to questions themselves. Instead, physical activity level is
collected with tools such as physical activity motion detector monitoring (such as a pedometer, or
accelerometers).
Modern technologies (e.g., mobile phones, GPS technology), which track movements of the individual,
could also be a solution. This must be assessed carefully, however, as accurate instruction and compliance of
the individual is required as the main basis for gaining reliable information. Only if the person actually uses
the pedometer appropriately, can it monitor physical activity correctly. The devices mentioned are normally
small and not cumbersome for the client. They are affordable and come in a variety of brands, most of which
should be reliable and valid.
Attendance rates within a recreation center can also be used as an objective observational measure. If
members of a recreation center have to check in for their training, these measurements are relatively objective.
However, if people forget to check in for a training or someone else checks in for the client, data might be
inaccurate. Errors may be occurring if one is not only interested in attendance rates but also general physical
activity during the day—e.g., people may also train in other environments (such as a park).
Typical physiological objective measures (Table 2.4) capture the physical activity level, or fitness and
functionality of the individual. Physical activity and fitness are related but not the same. Behavior can lead to
an improvement in fitness and functionality, and lack of fitness and functionality may obstruct behavior.
TABLE 2.4 Examples of Objective Measures to Assess Physical Activity Level and Physical Fitness
Measure of … Test and Material Needed (Example)
50
… Physical activity
Number of steps Pedometer
Acceleration forces Accelerometer, GPS, mobile phones
… Physical fitness
Cardiovascular fitness VO2Max test (spiroergometry) on the treadmill, stationary bike, rowing machine etc.
Rockport 1-mile walk test
Heart rate / heart rate variability Heart rate measurement device
Grip strength Hand grip dynamometer
Flexibility Measure tape/stick
Postural stability Force platform, one leg stance
Case Scenario 2.2
Let’s think again about the physical activity of individuals connected to the university. A task force of
researchers decides to speak with students, faculty, staff, and alumni, as well as family of staff, and
people living in the neighbor hood of the campus, to obtain information about these individuals’
physical activity levels. The goal is to learn more about their past behavior and experiences at the
university, what they like and dislike about the fitness options at the campus, and whether they want
support in committing to a weekly routine of physical activity. The process is as follows: First, the task
force selects a group of participants representative of the population. To do this, three to five individuals
from each group are selected, recruited, and interviewed.
Possible questions include:
• “Are you performing 30 minutes of moderate-intensity physical activity daily?”
• If no: “What challenges prevent you from doing so?”; “What could be changed to assist you in
becoming more active?”
• If yes: “What do you think would motivate inactive people to be as active as you are?”
Next, closed-end questions are developed on the basis of those answers. The generated questions are
sent out by e-mail to all students, faculty, staff, and alumni. Family of staff are to be approached
personally. All people of interest then receive questions like:
• “If you think about the following potential changes on campus, would they help you perform 30
minutes of moderate-intensity physical activity daily?” Please indicate your answer on the following
scale from “not at all” (1) to “very much” (6).
(a) If you get tips on how to schedule your training into your working day. 1–2–3–4–5–6
(b) If you get (more) personal assistance during your workout. 1–2–3–4–5–6
(c) If your friends and/or family could work out with you. 1–2–3–4–5–6
This allows people to indicate their past behavior and beliefs.
We now know something about the individuals who answered the questions. With that, we can tailor
our interventions to the needs of the individuals.
51
TAKE-HOME MESSAGES
When assessing behavior, both objective and subject measures can be collected. Motivation and other
psychological variables (see the following sections) are typically measured by perceived or subjective
means. The variety of objective and subjective assessment options provides a number of different
advantages, but also several restrictions. One should be aware of these when choosing a measurement
tool or designing a project.
OBTAIN HEALTH INFORMATION/HISTORY TO ENSURE SAFE

PARTICIPATION IN PHYSICAL ACTIVITY AND EXERCISE
Knowing about the health of oneself or of a client is important in order to exercise appropriately. The
health status determines whether a specialist should be consulted to evaluate the safety of exercising.
The recommended preparticipation questionnaires according to ACSM’s Guidelines for Exercise Testing
and Prescription (3) are the Physical Activity Readiness Questionnaire (PAR-Q, 22, 23) and the
AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire. For a more specific,
in-depth, and detailed preactivity screening process, the PAR-Q and AHA/ACSM Health/Fitness
Facility Pre-participation Screening Questionnaire may be combined with tools like the Health Risk
Appraisal (HRA) or Health History Questionnaire (HHQ) (24).
These four assessment tools—the PAR-Q, the AHA/ACSM Health/Fitness Facility
Preparticipation Screening Questionnaire, the HRA, and the HHQ—are all standardized
questionnaires used to identify health risk factors of exercising for an individual. Their purpose is to
obtain medical clearance for a person, refer a person to his or her doctor, use the information to modify
their program, etc. Thus, it is important for both the individual who intends to start exercising, and the
professionals who provide the environment, to know about any risk factors and contraindications.
Moreover, such assessments provide the opportunity to follow up with clients over time and track
improvements and obstacles, and should therefore be repeated on a regular basis, perhaps weekly or
annually. More detailed variations of the PAR-Q exist: The PAR-MEDX and the PAR-MEDX for
Pregnancy are longer questionnaires. If individuals respond to these more detailed versions properly,
exercise prescription can be done more accurately. (See From the Practical Toolbox 2.1 for more
information about the PAR-Q, the PARmed-X, and the PARmed-X for Pregnancy.)
The four assessments can be found on the Internet as follows:
• PAR-Q at http://www.csep.ca/english/view.asp?x=698
• AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire at
http://circ.ahajournals.org/content/97/22/2283.full.pdf
• HRA at http://www.cdc.gov/nccdphp/dnpao/hwi/downloads/HRA_checklist.pdf
• HHQ at http://www.hr.emory.edu/blomeyer/docs/HealthHistoryQuestionnaire2007.pdf
Two of these assessments will be described briefly in the following subsections.
SCREENING FOR EXERCISE PREPAREDNESS

Lauren Capozzi and S. Nicole Culos-Reed
When screening someone for exercise, it is important to recognize certain population characteristics
that may be contraindicated. Using the appropriate screening tool is the first step to ensuring
someone’s safety.
52
PAR-Q and YOU
This questionnaire is for people aged 15–69. This one-page form helps people to know if they need
to check with their physician before engaging in physical activity. See Figure 2.3; this form is also
available at http://www.csep.ca/english/view.asp?x=698.
PARmed-X
This is a physical activity–specific checklist used by physicians with patients who have responded
“yes” to one or more questions on the PAR-Q. This form is available at
http://www.csep.ca/english/view.asp?x=698.
PARmed-X for Pregnancy

This is a physical activity–specific checklist used by physicians with patients who are pregnant prior
to attending prenatal fitness class or performing other exercise. This form is available at
http://www.csep.ca/english/view.asp?x=698.
AHA/ACSM Health Fitness Facility Preparticipation Screening

This form (see Figure 2.4) provides an in-depth analysis of specific cardiovascular and other risk
factors that could be affected by physical activity participation. It also recommends whether or not
someone needs to contact his or her health care provider prior to exercise.
Informed Consent
This form (see Figure 2.5) ensures that individuals are aware of exercise testing and training
procedures and that both parties (the individual and the exercise professional) understand the
implications related to all possible outcomes.
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FIGURE 2.3. Par-Q & You, Physical Activity Readiness Questionnaire (PAR-Q) form. Reprinted from Canada’s Physical Activity
Guide to Healthy Active Living [Internet]. Ontario (Canada): Public Health Agency of Canada; [cited 2007 Jun 15]. Permission
from the Canadian Society for Exercise Physiology, http://www.csep.ca. © 2002.
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FIGURE 2.4. AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire. Individuals with multiple CVD risk
factors should be encouraged to consult with their physician prior to initiating a vigorous-intensity exercise program as part of good
medical care, and should progress gradually with their exercise program of any exercise intensity. ACSM, American College of
Sports Medicine; AHA, American Heart Association; CVD, cardiovascular disease, PTCA, percutaneous transluminal coronary
angioplasty. Reprinted with permission from American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and
Prescription. 9th ed. Baltimore (MD): Lippincott Williams and Wilkins; 2014; modified from American College of Sports Medicine
Position Stand, American Heart Association. Recommendations for cardiovascular screening, staffing, and emergency policies at
health/fitness facilities. Med Sci Sports Exerc. 1998;30(6):1009–18.
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FIGURE 2.5. Sample of informed consent form for a symptom-limited exercise test. Reprinted with permission from American
College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott Williams
and Wilkins; 2014.
Physical Activity Readiness Questionnaire (PAR-Q)

The PAR-Q (22,23), shown in Figure 2.3, is a general screening tool that can identify factors that increase
one’s risk for exercise-related health problems. The assessment can be performed by means of a self-
administered questionnaire, or with the assistance of a professional.
The questions can be answered with “yes” or “no” responses. Sometimes the answering option “I do not
know” or “I do not remember” is also provided. The questionnaire provides direct feedback on the provided
answers. If individuals answer “yes” to any items, they should see a physician prior to beginning an exercise
program.
Health History Questionnaire (HHQ)

Like the PAR-Q, the HHQ (15) is a tool to screen for risk factors prior to starting physical activity. The
HHQ, however, is much more detailed. The first seven items in section I: “I. Physical activity screening
questions” assess risk factors with questions such as:
• “Do you know of any other reason why you should not participate in a program of physical activity?”
In section II: “II. General health history questions,” 10 further questions evaluate medical conditions such
as stroke, diabetes, asthma, orthopedic conditions, high blood pressure, back problems, pregnancy. The HHQ
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also directly assesses physical activity routines and medications:
• “Do you currently exercise less than 1 or more hour per week? If you answered yes, please describe your
activities…”
• “Are you currently taking any medication that might impact your ability to safely perform physical
activity?”
With the HHQ, feedback has to be given by the professional who is supervising the interviewed person.
Thus, the professional must be fully aware of when information represents a risk factor, such as individuals
with diabetes who take medication. In these situations, the individual must be advised by their physician to
synchronize his or her medication and physical activity in order to prevent adverse reactions. In the case of risk
factors or diseases, the professional should recommend consulting a physician for medical clearance. Objective
measures to assess health are described in Table 2.5. These measures have been used and validated as objective
indicators of health (18).
To illustrate, consider Case Scenario 2.3.
TABLE 2.5 Examples of Objective Measures to Assess Health
Measure Test and Material Needed (Example)
Waist-hip-ratio, abdominal girth Tape measure
BMI, body fat (Normed) Weighting machine, tape measure
Resting heart rate, blood pressure Blood measure measurement device
Grip strength Hand grip dynamometer
Postural stability Force platform, stop watch
Lung volume Spirometer
Case Scenario 2.3
Yuri Arcurs/Shutterstock.com
Professor R is over 60 years old and suffers from frequent back pain. He knows that specific physical
training would be beneficial for his back. Although he experienced in the past that strength training
improves his back pain and his general well-being, he is apprehensive to attend the training offered at
the university recreation center. He feels he is too old, and that younger colleagues might take part in
this class as well and do much better than he would do. So far, he has neither managed to participate in
a class at the local sports club nor perform the exercises a physiotherapist showed him some time ago.
He would be more willing to start exercising immediately if a fitness center was built on campus that is
equipped with resistance training machines and personal trainers. This has materialized now, and
Professor R walks straight to the center.
The personal trainer meets Professor R. What should he know about Professor R? What should he
ask him, and how?
TAKE-HOME MESSAGES
Assessing medical conditions and possible contraindications for meeting general physical activity
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recommendations is an important step to prevent risks during exercising. Different assessment tools
exist that can help professionals advise their clients. Moreover, these tools can help individuals in
assessing their own challenges, and they can simplify the decision of whether or not one should talk to a
physician. These approaches can make physical exercise safer, and prevent injuries and bad experiences,
as well as support professionals in doing their work and improving maintenance within a program.
ASSESSING PHYSICAL ACTIVITY
Physical activity behavior can be performed at very different levels: mild, moderate, or vigorous. What is
good for whom, and what are the recommendations in general? If we look at general guidelines for
physical activity, the ACSM (3) recommends 30 minutes of moderate-intensity daily aerobic physical
activity 5 days a week, or 20 minutes of vigorous-intensity daily aerobic physical activity three days a
week, supplemented by 2 days a week of strength training, in order to create health benefits. Activity can
be performed as part of daily life, in bouts of 10 minutes, or incorporated into a sports program.
Recommendations differ with regard to body weight and the general aim of the physical activity (Table
2.6). These recommendations are similar to the 2008 PA Guidelines (4,8,13).
Thus, it is important to assess what the aim of the physical activity is, at what intensity level
individuals perform the physical activity (it should be a moderate- or vigorous-intensity activity), and
whether the recommended amount of minutes per week is achieved. As outlined in the “Assessment
Modes” section of this chapter, this could be measured by observation (e.g., monitoring attendance
rates), by objective measures (e.g., pedometers), or by directly asking the person (i.e., subjective measures
/ perceptions). In the following subsections, we present some examples of assessment tools to measure
behavior at the individual level. The following references provide a good illustration for such tools:
Godin Leisure-Time Exercise Questionnaire (9) and the modified versions of the Godin Leisure-Time
Exercise Questionnaire (9,17). Other examples are described in Table 2.7.
Different validated questionnaires exist, which assess physical activity behavior in comparable ways
(16). Results of the questionnaire or the information gathered via questionnaire can provide useful
information for developing interventions as we learn what people actually do, and where options for
improvements may be (for a list of comparable tools, see reference 16, Table 2.7 and the “Web
Resources” subsection in the References list).
TABLE 2.6 Recommendations for Weight Loss and Prevention of Weight Gain by the American College of Sports
Medicine (4,8)
Moderate Physical Exercise should be Performed with the Aim of … By…
…Preventing overweight (Body Mass Index ≥ 25) …Exercising 150–250 minutes per week
…Reducing overweight by exercising …More than 300 minutes per week
…Maintaining successful weight reduction …Exercising more than 250 minutes per week
TABLE 2.7 Overview of Physical Activity Measures
Name of Questionnaire (Reference) Dimensions Number of Items / Time to Complete

Questionnaire
Godin Leisure-Time Exercise Questionnaire Leisure, sports 3 items, 2–5 min

(GLTEQ)
Baecke Questionnaire (BAECKE) Work, leisure, sports 16 items, 12–15 min
International Physical Activity Questionnaire Work, leisure, domestic and garden 27 items, 15–20 min
(IPAQ long version) activities, sports
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International Physical Activity Questionnaire Work, leisure, domestic and garden 7 items, 5–7 min
(IPAQ short version) activities, sports
Source: https://sites.google.com/site/theipaq/
TABLE 2.8 Measurement of Different Intensities of Physical Activity, with Explanations
Intensity Content/Examples
Vigorous physical activities Heart beats rapidly, sweating
Moderate physical activities Not exhausting, light perspiration
Mild physical activities Minimal effort, no perspiration
Levels of Physical Activity

By means of the Godin Leisure-Time Exercise Questionnaire (GLTEQ) (see Table 2.8), one can measure
how much behavior was performed during the last month. Behavior is measured in terms of the effort of
activities. Clients are asked to report (a) their average number of sessions per week, and (b) the average
duration of a session.
Responses for each of these three activity categories can be computed as the product of frequency and
duration of physical activity. This can be done for each of the three levels, or as a sum scoring all three
together: vigorous and moderate activities on one hand, or vigorous, moderate, and mild activities on the
other hand. Alternatively, the three may be used as single indicators. As a result, an approximation of energy
expenditure is obtained. A caveat of the GLTEQ is that it does not take different domains of physical activity
into account. Physical activity can only be accounted for by means of physical exercise (Figure 2.6).
Domains and Components of Physical Activity

Since physical activity is not only performed as planned physical exercise, it may be worth considering the
domain of activities: If interventions target specific subdomains, then these subdomains should be evaluated
extensively as well (Figure 2.6). This can be done by assessing behavior with a rating scale that takes the four
domains of physical activity shown in the next section into account.
SPECIFIC PHYSICAL ACTIVITY DOMAINS AND THEIR INTERRELATIONSHIPS

If the goal is to explain variance in behavior, domain-specific physical activity (such as physical exercise vs.
active commuting) is impacted more easily by domain-specific variables. For instance, a domain specific
variable that impacts physical activity is self-efficacy. This can be compared in the following ways: self-efficacy
to perform fitness activities versus self-efficacy to commute to work, or motivational self-efficacy important
for behavior initiation (starting a new behavior) and volitional self-efficacy imperative for behavior
maintenance (see the “Evaluate Clients’ Resources” section of this chapter). In contrast to domain-specific
activity, if general physical activity (including, for example, commuting and household activities) is
considered, specific variables explain less of the behavioral variance.
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FIGURE 2.6. Domains and components of physical activity, there may be partial overlap (Please note: Physical activity while doing work- and
home-related duties is typically not a target of interventions.).
In clients, physical activity recommendations have to be modified accordingly. The ACSM provides
specific exercise recommendations for older adults and individuals with chronic conditions (13).
For example, the recommended goal behavior is 3×40 minutes for cardiac clients per week. Clients can
indicate frequency and duration of each behavior area by ticking one of the following options: “less than one
time per week for 40 minutes” (1), “at least one time per week for 40 minutes” (2), “at least three times per
week for 40 minutes” (3), “more than three times per week for 40 minutes” (4). Answers can then be
categorized in such a way that a dichotomous variable results—for example, whether clients performed at least
the recommended activity level (1) or not (0). Alternatively, such a Likert scale provides more information
about the individual, as well as potential for improvements.
The two measures mentioned in the previous section (4 or 2 answering options) capture mainly:
• weekly frequency of physical activity due to leisure time physical activity, and
• weekly frequency of physical activity while commuting.
However, two other facets may also be considered. These other considerations include:
• weekly frequency of physical activity due to work, and
• weekly frequency of physical activity due to house and garden duties.
To assess these areas of activity, a questionnaire might ask the following questions: “In the last four weeks I
have…”
• “…performed specific physical activities and sports (e.g., at a fitness center, while playing soccer),”
• “…performed physical activity at work (e.g., carrying weights, extensive walking),”
• “…performed physical activity due to commuting (e.g., going by bicycle instead of using the car),” and
• “…performed physical activity due to daily chores (e.g., physically exhausting care giving, garden work,
climbing stairs, cutting the lawn, vacuuming).”
The items can be answered on a Likert scale (indicating the degree of agreement) or by indicating the
minutes and sessions per week. Questions like those described in the preceding bullets can also guide
observation (monitoring of physical activity behavior). This is illustrated in Case Scenario 2.4.
Case Scenario 2.4
Oleg Kozlov/Shutterstock.com
A group of gardeners is employed at a university to keep the campus in mint condition. They cut grass,
trees, and bushes; they tear out weeds; and they care for the flowers. Some of the gardeners work as lawn
mowers and transport compost with a little motorized vehicle. They carry heavy machines used for
garden vacuuming and reforesting trees, and others do a lot of shoveling and cutting.
All gardeners receive the offer to join the recreation center, but no one shows interest in exercising
here. How can we assess their activity level at work and in their leisure time? Should they be encouraged
to work out in the recreation center? If so, how?
TAKE-HOME MESSAGES
Learning about what kind of physical activity a client is already engaged in enables the improved
development of an appropriate exercise plan. Physical activity behavior can be performed in a variety of
settings, and consists of very different aspects. To capture these aspects appropriately, and to evaluate
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whether an individual is meeting the recommendations, questionnaires and interviews should address
different aspects of activities. Such questions can also guide observation (monitoring). Alternatively,
objective measures like pedometers can be used to assess physical activity level. All measures can provide
useful possibilities to follow up with the progress of behavior change:
• Scales to measure behavior (and other characteristics) (4)
• A collection of physical activity questionnaires for health-related research (16).
EVALUATE CLIENTS’ MOTIVATIONS
If our goal is to know more about human behavior and what drives it, we need to know more about
what exactly is going on in individuals’ heads: Are they motivated to become or stay physically active?
Do they intend to increase their exercising behavior? If our goal is to understand what drives human
behavior, we need to appreciate the desires that lead individuals to become or stay physically active. This
specific inquiry can be titled “motivation.” People might be motivated to perform the recommended
physical activity, which is an important prerequisite for actually adopting the behavior. Similarly, if
people lack motivation, it is unlikely that a change in behavior will occur. Thus, it is essential to obtain
more knowledge about the “readiness” for behavior: how close persons are to actually changing their
behavior, or how far they have habituated a behavior.
Evidence
“Readiness to change” is a term typically used to capture even more than behavior and intention. “Readiness to
change,” also known as “stage (of change),” is conceptualized as a measurable indicator of behavior change and
its psychological antecedents. People may or may not intend to change their behavior, which can be measured
by intention assessments as well. Individuals could also be distinguished by whether they perform the
recommended behavior, which is also measured by the behavior tools described earlier. However, we need
further measures if we also want to know about the psychological characteristics: Are people performing
physical activity in a habituated way—in other words, are they already exercising for an extended period of
time? Are they at constant risk of stopping their exercise for certain periods at a time? We could use a special
question measuring habituation, such as “How difficult is it to be physically active?”, “I exercise regularly
without giving much thought to it”, or “How long have you currently been as physically active on a regular
basis as you are now?” The main advantage of measuring stages is the ability to unite behavior, intention, and
habituation into one measurement tool (see the following).
Motivation/Intention
Intention to perform behavior should be assessed in a way similar to behavior itself (Table 2.8). This could be
accomplished by rating the following three items: “I intend to perform the following activities at least 5 days
per week for 30 minutes…”
• “Vigorous physical activities (heart beats rapidly, sweating)”;
• “Moderate physical activities (not exhausting, light perspiration)”; and
• “Mild physical activities (minimal effort, no perspiration).”
Answers can be assessed (as behavior, see earlier) on a six-point scale from not at all true (1) to absolutely true
(6).
Intention should also refer to physical activity that is outside of work hours, and performed to an extent that
is at least moderate. Clients can indicate at what frequency and duration they intend to exercise (see earlier).
Again, answers can be categorized in such a way that a dichotomous variable results (active enough or not).
Whether cardiac [orthopedic] clients intend to perform at least the recommended activity for three [two]
times per week for 40 [20] minutes (1) or not (0); or whether a nonclinical person intends to perform at least
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the recommended activity, five times per week for 30 minutes (1) or not (0).
Stage of Change
According to stage theories (cf. Chapter 4), health behavior change consists of an ordered set of categories or
“stages” into which people can be classified (14). These categories reflect psychological or behavioral
characteristics such as motivation and physical activity behavior.
Classical stage assessments take time frames (e.g., 30 days; half a year) into account (18). Contemporary
assessments measure stages without using a specific time frame (10, 11). Individuals could potentially be asked to
think about the last month, and then can be presented with the following question:
• “Did you engage in physical activity for at least 5 days a week for 30 minutes or more?” Replying with
“yes” or “no” responses.
Further, they should be asked: “For the following month, do you intend to perform physical activities five
times per week for 30 minutes or more?”—with possible answers being “yes” and “no.”
Those individuals who indicate they were active in the past are then categorized as actors. People who
answer that they were not active, but do intend to perform the recommended goal activity, are labeled
intenders. Individuals answering that they have not been active, and are not intending to perform the
recommended goal activity in the future, are classified as nonintenders. An example of a more refined stage
assessment is shown in Table 2.3.
Based on their answers to the rating scale, individuals are categorized as nonintenders, intenders, or actors.
Alternatively, people can be categorized into the following stages (see Figure 2.7):
1. precontemplation
2. contemplation
3. preparation
4. action
5. maintenance
The assessment can also be adapted to other behaviors that are relevant for health promotion (see the
“Assessing Other Health Behaviors” section later in this chapter).
TABLE 2.9 Intervention Matrix for Health Action Process Approach (HAPA)-Based Stage-Specific Treatments
With the necessary information, interventions can be tailored to psychological and behavioral characteristics
of the stages. These are known as stage-specific interventions. We can capture stage movements prior to or
after the actual behavior change by measuring stages, rather than just behavior (e.g., development of an
intention when moving from the nonintentional stage to the intentional stage). These changes might be
important if we are interested in following up with changes that might not be visible in behavior change. If
the stage assessment is filled out repeatedly—for instance, every half year—it could provide information as to
whether individuals are moving forward or backward between stages, a success that might not be visible with
behavior measures alone (cf. Figure 2.7). Sharing feedback about these changes can be an important strategy
to motivate individuals, as it provides opportunities for ipsative feedback (individual frame of reference) in
contrast to mere normative standards (external frame of reference).
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FIGURE 2.7. Motivation and behavior of individuals in different stages. HAPA=Health Action Process Approach (20);
TTM=Transtheoretical Model (19); PC=Precontemplation; C=Contemplation; P=Preparation; A=Action; M=Maintenance.
Case Scenario 2.5
Once again, we invite you to think about the university example. This time we would like to know more
about what the university members think and feel with regard to exercise—that is, their motivation to
engage in exercise behavior. We therefore use the previously described questionnaires to assess the
behavior of three selected people. Person A reports exercising on the campus once a week, and would
like to extend her training program. Person B expresses that she is not doing anything and person C
states that she is physically active every day for at least 30 minutes, but not on the campus.
If we compare the reports with the recommendations, person A and B would both be regarded as
insufficiently physically active. Further, as there is a difference between A and B, what should we ask
those people to learn about their motivation to exercise? Person C is meeting the recommendation, but
still, is there anything that might be important to ask?
TAKE-HOME MESSAGES
If we measure motivation or assess the stage of an individual, we can gain much insight into the
“readiness” of an individual to become and remain active. Intention and motivation are important
determinants of behavior. Stage assessments also include behavioral aspects, which opens avenues for
fast measurements of where people are in the behavior change process, and how close they are to the
goal behavior. Such measurements can provide the basis for successful interventions in helping
individuals to adopt and maintain their goal behavior.
EVALUATE CLIENTS’ RESOURCES
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Existing theories of such health behavior approaches are the Social Cognitive Theory (SCT, 5), the
Theory of Planned Behavior (TPB, 2), and the Health Action Process Approach (HAPA, 20,21).
The HAPA has the advantage that it is a hybrid model, combining continuous models (like the SCT
and the TPB) and stages of change (21). However, it is more parsimonious than other stage theories,
which makes it easier to address the stages in interventions (21). The HAPA postulates when certain
variables are imperative for stage movements (see Table 2.9).
These variables, which will be described in the following subsections, can function as resources for
successful behavior change if they are high enough. If they are not high, they can be targeted in
interventions to facilitate behavior change.
The HAPA distinguishes between three stages of behavior change (Nonintender, Intender, Actor).
In the initial motivation phase of behavior change, known as the nonintentional stage, a person develops
the intention to act. Risk perception is seen as a distal antecedent (e.g., “I am at risk for cardiovascular
disease”), but is itself insufficient to enable a person to form an intention or to change behavior. Instead,
it serves to enable contemplation processes and further elaborates the thoughts about consequences and
competencies of potential risk behaviors. Similarly, positive outcome expectancies (e.g., “If I exercise five
times per week, I will reduce my cardiovascular risk”) are chiefly seen as being important during the
motivation phase, when a person balances the pros and cons of certain behavioral outcomes. Further,
one needs to believe in his or her self-efficacy, which is one’s ability to perform a desired action (e.g., “I
am capable of performing my exercise schedule despite the temptation to watch TV”). Self-efficacy
operates in concert with positive outcome expectancies, both of which contribute substantially to
forming an intention.
These beliefs are needed to form intentions in order to adopt difficult behaviors, such as regular
physical exercise. If the intention is successfully formed, the following phase is entered (the intentional
stage). This second phase is labeled as volitional, since the regulation of behavior is under volitional
control. After a person develops an inclination toward a particular health behavior, “good intentions”
must be transformed into detailed instructions explaining how to perform the desired action. However,
it is not sufficient to only initiate an action; maintenance of the action is important as well.
Maintenance of the action is achieved by self-regulatory skills and strategies, such as social support.
Social support can be conceptualized as either a self-regulatory barrier or a self-regulatory resource.
Missing social support can be a barrier to maintaining behavior, whereas instrumental, emotional, and
informational social support can enable the adoption and continuation of behaviors. This was found in
many exercise studies with chronically ill people, such as individuals with diabetes (17). Another
important self-regulatory factor is action and coping planning, as this enables translation of intentions
into behaviors, and maintenance of the behaviors in spite of potential obstacles. Measurements of these
variables will be outlined in more detail in the following subsections.
Risk Perception
Risk perception can be measured by items such as “How high would you estimate the likelihood that you will
ever have one of the following diseases: (a) cardiovascular diseases (e.g., heart attack, stroke), or (b) diseases of
the musculoskeletal system (e.g., osteoarthritis, herniated vertebral disk)?” Any health risk can be added to this
measurement, which is especially recommended if the clients harbor diseases / health risks. Responses should
be given on a Likert scale like “very low likelihood” (1) and “very high likelihood” (6).
Outcome Expectancies
Positive outcome expectancies (pros) and negative outcome expectancies (cons) can be assessed with the first part of
the statement:
• “If I engage in physical activity at least five times per week for 30 minutes…” and a following second part
of potential statements assessing pros and cons.
Pros are measured with items such as:
• “I would feel better afterward.”
• “I will meet friendly people.”
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• “My ability to stretch would increase.”
Cons can be assessed by items such as:
• “It will probably cost me a lot of money every time.”
• “I would have to invest a lot (e.g., into organizing my weekly schedule).”
Answers for pros and cons are assessed using six-point scales ranging from totally disagree (1) to totally agree
(6). If cons outreach the pros, professionals can work with their clients on these beliefs and barriers.
Self-Efficacy
Self-efficacy can be subdivided into motivational self-efficacy and volitional self-efficacy. Motivational self-
efficacy is imperative for generally getting started, while volitional self-efficacy is rather important for
maintaining a routine and getting back on track.
MOTIVATIONAL SELF-EFFICACY
Motivational self-efficacy is measured with the statement “I am certain …” followed by one of two items: 1. “…
that I can be physically active on a regular basis, even if I have to mobilize myself” or 2. “…that I can be
physically active on a regular basis, even if it is difficult”.
VOLITIONAL MAINTENANCE SELF-EFFICACY

Volitional maintenance self-efficacy is measured with the statement “I am capable of performing physical
exercise on a regular basis…” followed by one of the two items:
1. “…even if it takes some time until it becomes a routine,” or
2. “…even if I need several trials until I am successful”
Volitional self-efficacy on recovery self-efficacy can be described as: confidence to resume a physically active
lifestyle, although at times physical activity was not present; or the confidence to resume regular exercise after
failures and be prepared for possible failures in the future; and finally, the confidence to resume physical
activity after suffering from an illness. The items for volitional self-efficacy on recovery self-efficacy can be
worded as: “I am confident that I can resume a physically active lifestyle, even if I have relapsed several times
in my life” or “I am confident that I will be able to resume my regular exercises after failures, and that I will be
able to brace myself for possible failures” or “I am confident that I can resume my physical activity, even when
feeling weak after suffering an illness.” Answers can be assessed using six-point scales ranging from totally
disagree (1) to totally agree (6).
Action Planning and Coping Planning

Action planning is making a plan to actually perform the intended behavior. Coping planning is a strategy of
what to do in the face of barriers.
ACTION PLANNING
Action planning can be assessed with four items addressing the conditions of when, where, and how. The items
could be worded: “for the month after rehabilitation, I have already planned…” (1) “…which physical activity
I will perform (e.g., walking),” (2) “…where Iwill be physically active (e.g., in the park),” (3) “…on which days
of the week I will be physically active,” and (4) “…for how long I will be physically active.” Answers can be
assessed using six-point scales ranging from totally disagree (1) to totally agree (6).
COPING PLANNING
Coping planning can be measured with the statement “I have made a detailed plan regarding…” and the items
(1) “…what to do if something interferes with my plans,” (2) “…how to cope with possible setbacks,” (3) “…
what to do in difficult situations in order to act according to my intentions,” (4) “…which good action
opportunities to take,” and (5) “…when I have to pay extra attention to prevent lapses.” These items are
measured with a six-point rating scale ranging from never (1) to always (6).
Social Support
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Perceived social support can stem from different sources, such as family and friends. Social support regarding
physical activity can be assessed with 10 items. First, individuals are asked to rate “my family…” and second,
to rate “my friends…” with the following items: (1) … encouraged me to perform my planned activities, (2)
… reminded me to engage in physical activity, (3) … helped me to organize my physical activity, (4) …took
care of my home, giving me the possibility to engage in physical activity, (5) …joined my physical activity
program. Alternatively, friends and family can also be combined in order to gain one single item stem. The
answers should be given on a six-point rating scale ranging from never (1) to always (6), or from totally disagree
(1) to totally agree (6). Generally, clients appreciate if the answering options are essentially equal throughout
the questionnaire or interview.
Case Scenario 2.6
Charlotte Purdy/Shutterstock.com
An employee known as Mr. S receives an invitation for a test training in a new recreation center. He
was impressed by both the accessibility and high quality of the facilities. Prior to the first visit, he takes
part in a personal training session. The trainer tells him “I highly recommend that you come at least
three times per week and work out for 30 minutes or more, as this will improve your fitness and benefit
your health.” Mr. S replies “Yes, I will try to.” He is actually thinking, however, that this will not be
possible due to his work load and his other activities.
Over the course of the first weeks, he works out three times per week. In the subsequent six weeks, he
exercises only once per week. Coincidentally, Mr. S bumps into his trainer. His trainer asks him how his
workout routine is coming along, to which he replies that he enjoys working out once a week and
although he realizes he should exercise more often, his busy schedule cannot allow for it and he is
satisfied with his once-a-week routine
Perhaps Mr. S should be informed about risks and resources, trained to believe in his own
competencies, and supported in how to manage temptations. Any of these options may work, yet a
strong theory is needed in order to support individuals in a better way. A theory-and evidence-based
approach is the most effective way to understand the client’s problems, to develop a properly executed
intervention, and to know what to evaluate after the intervention (i.e., what steps should be taken at the
end of the personal training session), such as what would come after the personal training session.
TAKE-HOME MESSAGES
If the goal is to increase behavior and intention, specific factors should be addressed. Risk perception
and outcome expectancies are especially important for becoming motivated to change. Planning bridges
the gap between intention and behavior, and self-efficacy and social support are central factors in all
phases of behavior change. Thus, it is crucial to measure the level of these variables, so that any lack of
such resources can then be addressed in interventions.
ASSESSING OTHER HEALTH BEHAVIORS
Many people hold life goals that can drive different behaviors. For instance, individuals want to
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socialize, and therefore may engage in activities such as an exercise class with other people, going out for
a drink, or smoking. Other people strive for weight loss, and therefore engage in physical activity. At the
same time, they follow a specific diet and smoke to suppress their appetite and increase metabolism. A
third group might feel highly stressed, and therefore seeks relaxation by watching TV, engaging in
special physical activity like yoga, or consuming chocolate.
All of the previously mentioned groups perform physical activity, but with markedly different
motivations for executing the activity. All three also display other behaviors that might be beneficial for
their health, like following a healthy diet, or may be counterproductive such as smoking and alcohol
consumption, or TV watching. A recent study (12) demonstrated that those people who were watching
more TV gained more weight within 4 years (0.31 lb more weight for 1 hour more of TV watching per
day; http://www.nejm.org/doi/pdf/10.1056/NEJMoa1014296).
Different motivations result in different behaviors. For example, the socializing group X might also
be fitness-oriented. Thus, drinking alcohol and smoking is conflicting with the groups’ goal to become
and stay fit. Perhaps they refrain from smoking, but have no further will left for abstaining from
sedentary behaviors while in company.
Overall, looking at more behaviors besides physical activity might help to:
• comprehensively understand physical activity, as well as the occurrence of specific problems (Figure
2.4),
• understand why a behavior seems to be ineffective, although it should lead to a specific outcome
(such as weight loss),
• make people more satisfied with thriving in their life-goals, and
• improve the healthy lifestyles of clients.
Thus, the assessment and appreciation of other health behaviors is also important (Figure 2.8). This
can be done by examining the behavior as well as its determinants, such as intention toward the different
physical activities, or stages of change (10,11).
FIGURE 2.8. Interrelations between different behavior domains.
Health-Promoting Lifestyle Profile II (HPLP II)

The HPLP-II (24) measures the degree to which clients engage in an overall health-promoting lifestyle (24).
It consists of 52 items, which are divided into six subscales of a health-promoting lifestyle, such as physical
activity, nutrition, and stress management etc. Respondents are asked to indicate how often they engage in
each behavior (never, sometimes, often, or routinely). The advantage is that the habituated lifestyle factors are
assessed, not only single behaviors. Item examples are:
• “Follow a planned exercise program.”
• “Choose a diet low in fat, saturated fat, and cholesterol.”
• “Get enough sleep.”
• “Report any unusual signs or symptoms to a physician or other health professional.”
• “Expose myself to new experiences and challenges.” (24)
The main advantage of this self-report questionnaire is that it covers very different aspects. Also it has been
used in many previous studies. However, it is not clear whether the items measure behavior or attitudes and
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wishes. Thus, in the following paragraph we describe easy ways to measure different behaviors by means of
stage assessment, as stages contain both behavior and motivation, and stage assessments have very few items.
(See Figure 2.7 and Table 2.3.)
Dietary and Eating Habits

Regarding the fruit and vegetable consumption stage, the question should be “Please think about what you have
consumed during the last week. Did you eat five portions of fruits and vegetables per day?”
Alternatively or additionally, a balanced diet stage can be measured with the instruction: “Do you eat a
balanced diet on a typical day? A balanced diet consists of different aspects in addition to fruits and vegetables.
Particularly, the five facets are:
1. Choice and appropriate amounts of overall calories
2. Plenty of whole grains and potatoes
3. Moderate amounts of meat, meat products, and eggs
4. Decreasing fat and fatty food intake
5. Limiting sugar and salt intake”
Moreover, a healthy drinking stage can be assessed with “Please think about what you typically drink. Do you
drink 1.5 liters of nonalcoholic and noncaffeinated beverages (water, juice, fruit, and herbal tea) during the
day?”
All behaviors can be assessed in terms of stages (12; Figure 2.7; Table 2.3). Clients can respond by means of
a rating scale, with answering options being “no, and I do not intend to start” (precontemplation, PC), “no,
but I am considering it” (contemplation, C), “no, but I seriously intend to start” (preparation, P), “yes, but
only for a brief period of time” (action, A), and “yes, and for a long period of time” (maintenance, M). (See
Figure 2.7 and Table 2.3.)
Smoking
Smoking behavior can be assessed with the standard question: “Do you currently smoke cigarettes?” with a
yes/no response option. Current smokers should then be asked to indicate the amount of cigarettes they
smoke per day. If clients answer the question “Do you currently smoke cigarettes?” with no, they are then
asked, “Have you ever smoked cigarettes?” with a yes/no response option. Responses to these two items can be
used to classify respondents as current smokers, former smokers, or never smokers.
Alternatively, some authors also suggest asking directly, and letting individuals indicate the best matching
statement: “Are you a…”
1. “regular smoker?”
2. “occasional smoker?”
3. “ex-smoker (don’t smoke anymore, but used to)?”
4. “non-smoker (don’t smoke and never did)?” (33)
Alcohol Use
The alcohol consumption stage should be assessed with “Please think about what you typically drink. Do you
avoid drinking alcoholic beverages on a daily basis (less than a glass of wine or a bottle of beer per day)?” The
instruction is the same for all behaviors: “Please choose the statement that describes you best.” Clients should
be provided with a rating scale that has the following answering options: “No, and I do not intend to start”
(Precontemplation, PC); “No, but I am considering it” (Contemplation, C), “No, but I seriously intend to
start” (Preparation, P); “Yes, but this is very difficult for me” (Action, A); and “Yes, and this is very easy for
me” (Maintenance, M). (See Figure 2.7 and Table 2.3.)
Case Scenario 2.7
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Hugo Felix/Shutterstock.com
Student Y, an obese student, comes to the recreation center of the university and expresses her desire to
lose weight. She has tried different strategies, including regular physical activity. Although she works
out regularly, she has not managed to reduce her weight significantly. The instructor interviews her
about the kind of exercises she does, and some other lifestyle factors, such as her diet, which contains a
lot of fruits and vegetables, including potatoes. It turns out that student Y also has foods such as chips
and French fries in mind when talking about potatoes. Student Y admits that she drinks sugar-
sweetened beverages regularly. Furthermore, it becomes obvious that she gets less than 6 hours of sleep
per night on most nights during the week, and that she watches television for a couple of hours every
night.
Is there any chance we can provide support to reduce student Y’s body weight? Can a revised training
schedule help student Y? What should the trainer recommend?
TAKE-HOME MESSAGES
Physical activity and different behaviors are interrelated, not only in determining health, but also in
terms of facilitating and hindering each other, in which they work in orchestration. They can be driven
by equal or different goals. Other psychological mechanisms include the transfer of knowledge and skills
from one behavior domain to another: One might have learned how to plan the goal pursuit in one
behavior domain, such as how to do daily exercises for the back (regarding self-efficacy), and can now
apply these skills to another behavior domain, such as managing to commute actively by getting off the
bus one station early (with similar self-efficacy). People might also have severe problems with
coordinating different behaviors, such as being exhausted by active commuting or the attempt to stop
smoking, and then not feeling able to eat a healthy diet. To take this into consideration, different
behaviors should be assessed.
CHAPTER TAKE-HOME MESSAGES

Assessment is central when the aim is to better understand the individual, and his or her needs and
resources. Very different options for assessment exist. All have advantages and disadvantages, thus it is
important to decide what to measure and for what purpose. Further, we need information about one’s
motivation and experiences to optimally individualize and promote health behavior. On the basis of
such collected data, effective interventions can be designed, provided, and implemented. Furthermore,
on the basis of proper measurement, the effectiveness of interventions can be evaluated.
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3. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott
Williams and Wilkins; 2014.
4. American College of Sports Medicine. Exercise recommendations specifically for different health conditions [Internet]. [cited 2009. Available
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8. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine Position Stand.
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driven analyses in three international samples. International Journal of Behavioral Medicine. 2012.
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New England Journal of Medicine. 2011;364:2392–404.
13. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: Recommendation from the American College
of Sports Medicine and the American Heart Association. Medicine and Science in Sports and Exercise. 2007; 39(8):1435–45.
14. Nigg CR. There is more to stages of exercise than just exercise. American College of Sports Medicine. 2005; 33:32–5.
15. Pecoraro RE, Inui TS, Chen MS, Plorde DK, Heller JL. Validity and reliability of a self-administered health history questionnaire. Public
Health Rep. 1979; 94(3):231–8.
16. Pereira MA, Fitzer Gerald SE, Gregg EW, et al. A collection of physical activity questionnaires for health-related research. Medicine &
Science in Sports & Exercise Suppl to. 1997;29(66 Suppl):S1-205.
17. Physical activity guidelines for Americans [Internet]. [cited 2008. Available from: http://www.health.gov/paguidelines/ & FITT
dimensions].
18. Plotnikoff RC, Lippke S, Reinbold-Matthews M, et al. Assessing the validity of a stage measure on physical activity in a population-
based sample of individuals with type 1 or type 2 diabetes. Measurement in Physical Education and Exercise Science. 2007;11(2):73–91.
19. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. American Psychologist.
1992;47(9): 1102–14.
20. Schwarzer R. Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied
Psychology. 2008;57:1–29.
21. Schwarzer R, Lippke S, Luszczynska A. Mechanisms of health behavior change in persons with chronic illness or disability: the Health
Action Process Approach (HAPA). Rehabilitation Psychology. 2011;56(3):161–70.
22. Shephard RJ. PAR-Q, Canadian home fitness test and exercise screening alternatives. Sports Medicine. 1988;5(3):185–95.
23. Thomas S, Reading J, Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport
Sciences. 1992; 17(4):338–45.
24. Walker SN, Sechrist KR, Pender NJ. The health-promoting lifestyle profile: development and psychometric characteristics. Nursing
Research. 1987; 36:76–81. Tool available at: http://www.unmc.edu/nursing/docs/English_HPLPII.pdf
FURTHER WEB RESOURCES

BRFSS as an alternative questionnaire [Internet]. Available from: http://www.cdc.gov/brfss/questionnaires/english.htm.
Different validated scales to measure behavior and guide how to select a measurement [Internet]. Available from: http://toolkit.s24.net/physical-
activity-assessment/.
Physical activity resource center for public health: Database of physical activity measures from (University of Pittsburg) [Internet]. Available
from: http://www.parcph.org/assess.aspx.
Scales to measure different social-cognitive variables [Internet]. Available from: http://www.gesund heitsrisiko.de/docs/RACKEnglish.pdf.
Scales to measure self-efficacy, barriers, perceived severity, perceived vulnerability [Internet]. Available from:
http://dccps.cancer.gov/brp/constructs/.
Scales to measure social support [Internet]. Available from: http://userpage.fu-berlin.de/~health/soc_e.htm..
Schwarzer, R et al. Assessment and analysis of variables [Internet] [cited 2003. Available from: http://web.fu-berlin.de/gesund/hapa_web.pdf.]
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Our understanding of the factors that influence physical activity has shifted over the last 20 years (116).
Initially, there was considerable focus on the individual-level factors responsible for why some people
were active, while others were not. The reasons were considered within the realm of personal
responsibility, motivation, and self-discipline. Over time, this focus for understanding physical activity
has shifted to ecological models (129) that include individual, social, environmental, and policy factors
that all contribute to physical activity participation. While this approach is far more likely to yield an
overall accuracy in understanding physical activity, the focus on personal responsibility remains no less
important. Clearly, an individual holds a great amount of agency over whether they engage in physical
activity. Environmental access to exercise equipment and recreation facilities is very high in most
developed countries (27,42) and the social norms regarding the benefits of physical activity are very
positive across all ages (56,130,133). Indeed, personal motivation is described as the critical barrier
among people who are inactive (26).
Therefore, the skills and strategies that people can use in order to promote their own physical activity
is still of paramount importance to trainers and of key interest to clients. This chapter outlines the most
essential personal level strategies for building and sustaining physical activity motivation from prior
research efforts. We begin by outlining the findings from individual-level theories used to understand
regular physical activity behavior and then apply this evidence base to guide practitioners and users with
skills and strategies to improve or sustain motivation. Throughout this chapter, we refer to worksheets
to assist in these approaches. These worksheets can be found in From the Practical Toolbox 3.1 through
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3.6. See also Table 3.2, a decision tree for appropriate uses of these strategies, and the sample case
scenarios presented toward the end of this chapter.
EVIDENCE: THE INTENTION-BEHAVIOR GAP
Most of us can immediately understand the gap between our good intentions and behavior by thinking about
New Year’s resolutions. Getting more exercise or eating healthier are often our most popular “self-promises,”
but they can also include other areas of personal improvement, such as spending more quality time with loved
ones, quitting smoking, exercising restraint over spending, or learning something new. Most of us also know
only too well that those initial intentions do not always pan out as planned. Psychological/behavioral theories
that have been used to guide physical activity intervention initiatives and explain behavior also include an
intention concept (12,46,90). Indeed, in almost all of these models, intention is viewed as the proximal
determinant of action (see Figure 3.1), much like our New Year’s Evening hopes.
Intention represents the decision to act on a behavior in its most modest conceptualization (96), to the
motivation required to act and organizational planning in its most conservative definitions (11,104). Overall,
intention has been validated as a dominant predictor of physical activity in adults (131). Clearly the intention
construct is important and, in any consideration of skill building or strategy, it would be prudent to consider
all critical factors that may influence intention. Our current intervention research and theoretical tests in the
physical activity domain have yielded a sound understanding of intent. Thus, the first part of our chapter
follows the best practice research on how to increase physical activity intentions.
BEHAVIORAL PALATE WORKSHEET

Your belief in your ability and your attitudes toward an activity influence whether you are physically
active. Belief in your ability to perform an exercise is an important part of both adopting a new
activity and adhering over the long term.
Step 1: What Types of Exercise?

Instruction: Think about the physical activities you can do as part of your new exercise regime. List
the type of exercises you prefer doing and your experience with each of these activities under
COLUMN A. Then, list some NEW AND EXCITING MODES OF EXERCISE that you
would like to try under COLUMN B, and lastly, list some CHALLENGING MODES OF
EXERCISE under COLUMN C. Now that you have brainstormed activities, rate your confidence
in your ability to perform/engage in each activity. Under EACH activity in EACH column also
record your experience with these activities.
Please use the example provided to help you.
COLUMN A COLUMN B COLUMN C

Exercise Preferences New and Exciting Challenging Modes of Exercise
Modes of Exercise
Example Exercise: Example Exercise: Wii Example Exercise: Swimming
Walking Fit
Confidence/experience: Slightly confident I
Confidence/experience: Confidence/experience: haven’t been swimming since swimming
Extremely confident. I Moderately confident. lessons when I was a kid, but I think a masters
walk my dog several I’ve never been a swim club would be a great way to meet new
short walks each day. videogamer, but it looks friends.
like fun.
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Exercise #1: Exercise #1: Exercise #1:
You will be more likely to persist in activities that you find enjoyable and interesting. Consider the
activities you brainstormed about in the preceding chart. What factors contribute to your enjoyment
of EACH OF THESE EXERCISES? How could you enhance your enjoyment of exercise? Please
write down the factors that influence your enjoyment of exercise in the following table.
Step 2: Exercise Enjoyment and Strategies to Enhance Enjoyment

Instruction: Under COLUMN A, list where you will exercise and its PROXIMITY to your home.
Under COLUMN B, list the AESTHETIC factors of the environment where you plan to exercise
that are pleasing. Under COLUMN C, list the ways to enhance your engagement in exercise,
including factors that increase your INTEREST in exercise, opportunities for SOCIAL interaction,
and other aspects that provide VARIETY to your exercise routine (e.g., listening to music).

Proximity Aesthetics Interest
Where will I exercise? Is the Is the location a How can I…
location where I plan to pleasant environment - make exercise more
exercise close to my home? for performing interesting/stimulating?
exercise? - involve friends and family or
others in exercise?
- incorporate variety, and other
aspects such as music to enhance
my engagement in exercise?
Location #1: Factor #1: Interest:
Location #2: Factor #2: Social:
Location #3: Factor #3: Variety:
DECISIONAL BALANCE WORKSHEET
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A helpful strategy when considering behavior change is to think about the benefits and the costs of
your current behavior and of changing your behavior. Record the costs and benefits of your current
behavior and of changing your behavior in the following table. Then, compare the costs and benefits
of your current behavior and the new behavior. Ask yourself: Why do I want to change my behavior
and become more active? What are the most important reasons?
Step 2. Take a look at your decisional balance worksheet. Ask yourself…
1. Why do I want to change my behavior and become more active?
2. What are the most important reasons for changing your behavior?
GOAL SETTING WORKSHEET
Step 1: Think about your goals.

Think about what you want to achieve for your physical activity and fitness. Brainstorm a few goals
that you want to get out of your new physical activity program. Write down the two or three goals
that come to mind on the lines below.
If you want to increase your chances of being successful, you should:

1. Set goals that you personally value and that reflect your personal interests. Strive to do something
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that you like doing and/or are interested in doing.
2. Set goals that are not only challenging, but are also achievable. Your goals should not be too hard
or too easy.
3. Set goals that are clear and specific. Research shows that people are less successful when their
goals are vague.
4. Set both short- and long-term goals. Make short-term goals along the way to reaching your long-
term goals.
To help you set goals that meet these guidelines, make them SMART.
SMART goals are specific (S; describe when, where, how, what), measurable (M; quantifiable),
achievable/realistic (AR), and include time frame considerations (T).
Step 2: Evaluate your goals.
Instruction: Take a look at your above goals. Are these goals SMART? Use the form below to help
you evaluate your goals.
Step 3: Reframe your goals using the SMART technique.

Instruction: Revise your goals below using the SMART technique. Remember SMART goals are
specific (S; describe when, where, how, what), measurable (M; quantifiable), achievable/realistic
(AR), and include time frame considerations (T). Design both short-and long-term goals.
Still, there are several advances in intention research within the physical activity domain that suggest some
modifications to our theoretical and practical use of intention may be necessary. Though intention is a
powerful predictor of physical activity, at least 70% of physical activity is not explained by intent. The
intention-behavior gap so well known to students of New Year’s resolutions is also present in our current
theories. Some of this gap may be due to the waxing and waning of intention strength. A recent review of the
moderators of the physical activity intention-behavior relationship showed that the temporal consistency of
intention is the most reliable and largest moderator (111). Thus, many people don’t really hold fast to their
intentions and have a strong sense of resolve. More problematic to the intention-behavior relationship
proposed in current theories, however, is the experimental evidence. For example, Web and Sheeran (141)
conducted a meta-analysis of experimental evidence in 47 studies linking intention and behavior. The findings
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demonstrated that a large change in intention subsequently resulted in a small change in behavior. This
demonstrated that while intentions and physical activity are correlated, a change in intention does not always
create a change in behavior. This meta-analysis was recently replicated with physical activity behavior
exclusively (112), and the results showed that changes in behavior, from changes in intention, may be even
smaller than other health behaviors. The results cast considerable doubt that raising intention alone will result
in increases in physical activity behavior.
PLANNING WORKSHEET
Most people fall short of achieving their goals because they don’t establish an adequate plan of action.
Research tells us that people who plan out how they will reach their goal are more likely to succeed.
This means that after you set a SMART goal you must then plan what you will do, how you will do it,
where you will do it, and when you will take action.
Step 1: ACTION PLANNING – What, where, and when will you engage in exercise?
Instruction: List the SPECIFIC EXERCISES you plan on doing under COLUMN A. Describe
the LOCATION where this exercise will be performed under COLUMN B, and then describe
WHEN you will perform that exercise under COLUMN C.
Please use the example provided to help you.

Exercise Where I will engage When I will engage in this activity?
Activity in this activity?
Example Where?: The park in When?: Monday, Wednesday, and Friday
Exercise: my community evenings between 6:00 and 7:00
Walking
Exercise #1: Where? When?
Now that you have established an action plan, it is important that you anticipate and manage
situations associated with performing unwanted behaviors and overcome barriers to the desired
behavior using effective coping strategies. Effective problem solving and coping strategies are
essential for translating intention into action and for maintaining a desired behavior or activity over
the long term.
Step 2a: Coping Planning – Exercise Barriers and Strategies to Overcome Them
General Instructions:
Please think about each exercise activity you listed in Step 1: Action Planning. Which obstacles or
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barriers might interfere with the implementation of each of your exercise plans? How could you
successfully cope with these barriers? Please write down your strategies to overcome EACH exercise
barrier in the following table.
Instructions:
1. In COLUMN A, list the exercise activities you identified in Step 1: Action Planning.
2. For EACH ACTIVITY you listed in column 1, identify EXERCISE BARRIERS that may
prevent you from performing the exercise activity under COLUMN B and STRATEGIES TO
OVERCOME the exercise barriers under COLUMN C. Try to think of the main barriers that
could get in the way of each activity and then strategies to overcome them.
Having trouble deciding how to reach your goal? There are a number of ways to reach a goal. Try
brainstorming as many ways to reach your goal as you can. Don’t worry about coming up with the
perfect plan. Instead, just get those creative juices flowing and write down all the options that come
to mind. You can use the following worksheet to eliminate options and to choose the method that is
most suitable for you.
Step 2b. Coping Planning: Substituting Alternatives

Instruction: There is more than one method to reach your goals, each with its own advantages and
disadvantages. Record your SMART GOAL below and generate a list of ways to meet this goal in
COLUMN A. Brainstorm the advantages and disadvantages for each option in COLUMNS B and
C. Compare the advantages and disadvantages for each option and assign a rank for each (e.g., 1 =
most likely to be successful, 3 = least likely to be successful).
What is your goal?
Recent research that has separated the intention-behavior relationship into quadrants provides an
explanation for the discordance (52,122); see Table 3.1. Specifically, intention-behavior relations are
asymmetrical. Only three of the four possible quadrants yield ample sample sizes: those who did not intend to
be active and subsequently are not active (nonintenders), those who intended to be active yet failed to meet
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these intentions (unsuccessful intenders) and those who intended to be active and succeeded in following
through with their intentions (successful intenders) (109). These results demonstrate that intention is a pivotal
construct but not sufficient to explain behavioral action on its own.
With this evidence in tow, the second half of our chapter is dedicated to the skills and strategies of
translating good intentions into behavior. Several recent theories have been postulated and tested for closing
the intention-behavior gap (53,54,98,126). We draw upon those findings to illustrate the best practice for
translating strong physical activity intentions into actual behavior.
BUILDING INITIAL INTENTIONS
Understanding critical determinants of intention to exercise and subsequent exercise behavior is essential in
helping clients maintain their positive intentions. Current research clearly identifies significant correlations
between many psychological constructs and intentions to exercise (17,66,134,136). Most of these variables,
however, are well represented under different names by two constructs contained within Social Cognitive
Theory (self-efficacy, outcome expectancy), the Transtheoretical Model (self-efficacy, decisional balance), and
the Theory of Planned Behavior (perceived behavioral control, attitudes) (11). For the purpose of this chapter,
these overlapping behavioral determinants of exercise will be grouped into the following two key constructs:
(1) the expected outcomes of exercise, and (2) perceptions of control over exercise. Related evidence-based
strategies or skills that the fitness and health professional can use with their clients to help them maintain
their positive intentions to be physically active will also be discussed.
EXERCISE CONTRACT
For each SMART GOAL you create, complete the following contract to show your commitment to
your goal. Refer to the contract regularly to remind yourself of your commitment.
1. Goal
2. How will I know if I have successfully reached my goal? List specific measurable behaviors
necessary to reach my goal. Also, describe when and how often these behaviors will be measured.
3. Support Team or Resources
4. Rewards and Time Frame
5. Signature
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SELF-MONITORING WORKSHEET
Journal and Tracking Log

Instruction: Each time you participate in your exercises, write down WHEN you did them in
COLUMN A, WHAT you did in COLUMN B, WHERE and WITH WHOM you did them in
COLUMN C, and HOW it felt in COLUMN D. In COLUMN E, write down any other
important comments or observations you made while exercising. Use the example provided to help
you.
TABLE 3.1 Intention-Behavior Relationship
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TABLE 3.2 Decision Tree for Choices of Worksheets and Strategies
FIGURE 3.1. Intention is viewed as the proximal determinant of behavior.
EXPECTED OUTCOMES OF EXERCISE
A recent review among nonclinical populations demonstrated that one of the most common approaches for
promoting physical activity is to focus on increasing expected outcomes (117). The client’s expected outcomes
toward physical activity may represent a variety of factors, such as the expected outcomes/consequences of
participating in physical activity behaviors, the advantages and disadvantages (pros/cons) associated with
engaging in physical activity, and the anticipated benefits and barriers to participation (46). The value or
significance the individual places on that desired outcome may also be important (i.e., if improving fitness is
highly valued by the individual, they will be more likely to engage in that behavior).
The construct, in various guises, is present in most of the theoretical models used in physical activity
promotion and explanation. For example, in the theory of planned behavior (5), the attitude construct
represents the summary thinking of expected outcomes of performing physical activity (e.g., good vs. bad).
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According to meta-analyses of the theory of planned behavior, attitude is the strongest predictor of exercise
intention (Symons Downs & Hausenblas, 41,60). This provides some evidence that our intentions may be
influenced by what we expect to occur from being regularly physically active. Recent research also suggests
that expected outcomes can be reliably distinguished in terms of either instrumental or affective properties
(48,79,103,106), and these affective properties may have greater impact on physical activity intentions than
instrumental properties. Affective expected outcomes refer to judgments about the pleasure/displeasure,
enjoyment, and feeling states expected from engaging in a behavior, while instrumental expected outcomes
refer to judgments about the costs and benefits of engaging in physical activity (79,114). Outcomes from
regular exercise that do not directly involve feeling states, such as improvements in fitness and physical
appearance, and reduced risk of chronic disease are instrumental; whereas outcomes that involve feeling states
derived directly from the exercise experience such as enjoyment, boredom, pain, exhilaration, stress-relief, and
satisfaction are affective. These two domains are also divided generally as proximal (affective) and distal
(instrumental) in terms of their derived outcomes (11,58). In support of this distinction, recent studies have
shown that affective attitude has better predictive ability than instrumental attitude in the physical activity
domain (48,100,114).
CHANGING EXPECTED OUTCOMES TOWARD PHYSICAL ACTIVITY
Best Practice Strategies

Expected outcomes are thought to derive most of their foundation from the individual’s knowledge base via
education or a cost-benefit weighing process. Decisional balance, a construct from the Transtheoretical Model
(96), is a decision making behavioral change strategy that may best encompass the weighting strategy. It
involves having the client weigh the pros and cons of changing their physical activity behavior (25,86) and
evaluate their beliefs about the benefits and barriers to becoming physically active.
Generally, weighing the pros and cons of engaging in a new behavior is particularly important in the initial
stages of engaging in an activity when an individual is likely to perceive greater costs and barriers to physical
activity than benefits. In support of the view that individuals are more likely to initiate a behavior if they
perceive favorable outcomes associated with it, a recent review found that providing information to
participants about the costs and benefits of engaging in physical activity produced significantly greater
improvements in physical activity than those that did not (143). Being satisfied and valuing these favorable
outcomes likely plays a greater role in sustaining physical activity behavior over time than the mere presence of
positive outcomes.
A decisional balance worksheet (see From the Practical Toolbox 3.2) is one tool that can be drawn upon to
help clients change their expected outcomes toward physical activity. Specifically, a decisional balance
worksheet can be used to help individuals identify their perceptions about the pros and cons of adopting a
physical activity behavior and the barriers (actual and perceived) to engaging in physical activity. Decisional
balance worksheets, in which the benefits and costs of physical activity are written down, have been found to
significantly increase exercise class attendance (e.g., 62,89). Once benefits and barriers are identified, possible
strategies aimed at enhancing benefits and minimizing barriers and shifting decisional balance in favor of
physical activity (i.e., so the benefits outweigh the costs) can be implemented.
When working through the benefits and barriers to engaging in physical activity with a client, it is
recommended that affective properties of physical activity are the focus. Focusing on instrumental/distal
outcomes such as weight loss, reduced risk of chronic conditions, improved function, fitness, and health will
likely have more limited influence on whether the client chooses to adopt physical activity into his or her
routine. Despite the negligible effects of instrumental attitude on physical activity (73,117), briefly educating
clients on the benefits of regular physical activity is an appropriate course of action and is typically a more
accepted approach than focusing on the hazards of inactivity. In fact, messages that are framed positively (i.e.,
benefits of regular physical activity) are typically better received than those with negative framing (65,72,92).
A handout briefly outlining the benefits of physical activity has been found to be effective in changing
instrumental expected outcomes toward physical activity (68). See Chapter 3 for an example of such a
handout.
When taking on the challenge of changing a client’s expected outcomes toward physical activity, place more
effort on helping clients to consider and focus on the exercise experience and the positive affective properties
associated with the exercise experience (e.g., enjoyment, intellectual stimulation, pleasant body states, mental
health). Despite the reliable and robust association between affective attitude and physical activity, few studies
have focused on modifying affective attitudes and the impact of these changed attitudes on physical activity
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intention and behavior (83,114). Several recent studies found that, in participants randomly allocated to either
a control (no message), an affective message group, or a cognitive message group, individuals in the affective
message group reported greater self-reported physical activity than other groups (34). Interestingly, the impact
of affective messages on self-reported physical activity was greatest in those with a high need for affect or a
low need for cognition suggesting that individual characteristics like preference for emotion or thinking may
be important when targeting attitude change. In addition, a recent study with adolescents found that in
inactive participants only, the affective message group had significantly greater increases in physical activity
compared to the instrumental messages, combined messages, and control groups (124). Although
confirmation of this finding and further exploration with different populations is needed, it appears that
interventions targeting affective expected outcomes may have a greater impact on physical activity in inactive
individuals.
In addition, print materials including messages targeting the stress-relieving and anti-depressive qualities of
physical activity has been effective in changing affective attitude and exercise behavior (33,92). Parrott et al.
found that print material targeting exercise enjoyment and mental health benefits of exercise was successful for
improving exercise among those individuals with higher baseline levels of affective expected outcomes (in this
case, attitude) but not effective for those with lower baseline levels. Caution needs to be exercised when
choosing to use print materials to persuade clients to exercise. Personality characteristics and previous
experience with physical activity should be considered. Focusing on the affective properties of physical activity
(e.g., enjoyment) may work as a useful prime or reminder for those who have found it fun and appealing in the
past, but it may be a futile approach with individuals whose affective experience with physical activity has been
negative (e.g., boring, unpleasant, tiring).
Substantial evidence points to the importance of enjoyment and psychological well-being in motivating
people to exercise (17,19,20). As such, creating opportunities for positive experiences with exercise, where
people can learn to reinterpret physical activity as enjoyable and good for mental health may represent a more
effective means to change expected outcomes. A second means of creating positive experiences with exercise is
through manipulating the physical activity environment. Research also suggests that individuals should engage
in physical activity in an environment that is aesthetically pleasing (e.g., exercising outdoors (93)).
Environmental aesthetics have been associated with both physical activity (64) and affective expected
outcomes (105,108). Having the client focus on environment, rather than on the affective experience (e.g.,
boredom, fatigue), may also improve the exercise experience through distraction. The behavioral palate
worksheet found in From the Practical Toolbox 3.1 can help you with this task.
A third means to improve affective expected outcomes toward physical activity is through the introduction
of novel, enjoyable, and engaging exercise activities. Rhodes and colleagues have demonstrated that interactive
videogame bikes result in better adherence to exercise prescription than standard exercise due to an increase in
affective expected outcomes (118,119). Thus, the selection of fun activities is paramount when possible. The
behavioral palate worksheet found in From the Practical Toolbox 3.1 can also be used to help guide the choice
of enjoyable activities.
Behavior modification strategies, including reinforcement control and contingency management, represent
additional methods to motivate individuals to become active through short-term modification of expected
outcomes (40). Reinforcement control involves increasing the frequency of the target behavior through
positive reinforcement (adding something positive) and negative reinforcement (removing something negative
(25)). This process introduces changes to the expected short-term outcomes of performing the act. Carefully
structuring the exercise prescription at the client’s level will be an important consideration in managing the
client’s immediate affective experience and increasing the likelihood that a client will perceive the exercise
experience as rewarding (21). Intensity of exercise is one means of influencing experiences with exercise, and
in choosing a starting intensity level a client’s past history with exercise and current fitness levels need to be
considered. High-intensity activities for clients who are resuming activity and are unfit are often deemed less
enjoyable (43). Early on in the stage of exercise adoption, the affective experience of exercise may be negative
(e.g., soreness, pain, discomfort, fatigue) and it may take time for the positive affective benefits of physical
activity to become reinforcing in themselves. In the interim, more immediate extrinsic rewards (e.g., praise,
concert tickets) and incentives may be required to help support engagement in the new behavior via the
placement of external expected outcomes. Thus, creation of sought-after rewards for adherences and
contingency structures are important strategies to help manage the consequences of physical activity. For
example, participation in other preferred leisure activities could be made contingent on performance of
exercise. Some caution should be applied to the utility of expected outcomes, more specifically external
rewards, and their effect on overall behavior change.
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TAKE-HOME MESSAGE
In summary, the expected outcome of physical activity is a well-demonstrated construct that has a
potential impact on building the intention to be physically active. Consideration of the affective
expected outcomes (e.g., pleasure, enjoyment) may be even more important than the instrumental
outcomes (e.g., reducing risk of chronic disease, improved fitness). The best strategies to improve and
change expected outcomes include decisional balance worksheets, information about the benefits of
regular activity, and choices of pleasant physical activities and exercise environments. It is also possible
that building in short-term expectations in the form of rewards or contingency scenarios may help
increase initial intentions, although caution should be employed when using these extrinsic sources
because they are unlikely to be sustaining.
PERCEPTIONS OF CONTROL OVER PHYSICAL ACTIVITY
A second major construct that the fitness and health professional needs to consider when helping their clients
increase positive intentions is perceptions of control (i.e., their degree of confidence) over engaging in regular
physical activity. Almost all theories of human behavior include a construct related to control over behavior
(12,46). For instance, self-efficacy is a construct from social cognitive theory, which is defined as one’s belief
in his or her capacity to perform a skill or behavior successfully (10,12). Similarly, perceived behavioral
control, a construct from the theory of planned behavior, represents a person’s perception of their capability
(i.e., perceived ease or difficulty) to perform the behavior, assuming he or she wants to (4,103). This
perception of control reflects beliefs regarding past experiences and current skills. Perceived behavioral
control/self-efficacy is one of the most reliable correlates of intention, comparable to expected outcomes of
physical activity (57,128,131). The challenge, however, is often to separate real control issues from motivation,
values, or affective expected outcomes (99,107). The best example of this difficulty may be with a
consideration of the most common barrier to control over exercise: lack of time (26). Most people cite lack of
time as the reason they cannot exercise, but actual leisure-time hours are not reliably linked to exercise
(exercisers have just the same amount of time in a day as non-exercisers), thus the statement appears to be
more of an excuse or cover for different values than a real control issue (22).
BUILDING PERCEPTIONS OF CONTROL OVER PHYSICAL ACTIVITY
Best Practice Strategies

Bandura (8,10) highlights the importance of four sources of information for self-efficacy:
1. Mastery experiences
2. Social modeling/vicarious experience (observing others similar to oneself experience success/cope with
challenges)
3. Verbal persuasion (e.g., praise, encouragement)
4. Judgments/interpretations of physiological/affective responses to exercise
These four sources, in diminishing value, are considered the important skills to build upon control
perceptions of physical activity.
Mastery experiences are probably best created through shaping (e.g., 25). Shaping is a strategy where
reinforcement is used to help the client gradually increase his or her physical activity levels and feelings of
competence. Begin by having the client participate in a behavior that he or she is capable of doing and then
gradually increasing intensity, duration, and frequency of activity (i.e., principle of progression). Choosing the
appropriate starting level is a tricky balancing game of managing interest and difficulty. Failure to consider the
principle of progression in exercise prescription may result in early attrition. The concept of mastery is
considered the most powerful influence on self-efficacy, so negative experiences and failure to achieve the
program can have deleterious consequences on self-efficacy. Thus, careful consideration of an achievable
program is important.
It is essential that clients feel confident in their capability to perform their physical activity program. To
enhance the client’s sense of control, ownership, and confidence in their behavior change, and to ensure their
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physical activity program is matched with their own preferences and lifestyle, the health professional should
get their client’s input in the development of the program or have clients write their own program with
guidance and support. With the help of the health professional, generating detailed instructions on the
specifics of how, when, and where to engage in the behavior is a useful additional means to enhance feelings
of control (67). Moreover, we suggest creating the opportunity for the client to have at least one positive
mastery experience in a setting chosen by the client (e.g., meeting at the local gym and working through the
prescribed exercises). Providing positive reinforcement—that is positive and specific—for small behavioral
successes and progress toward the desired goal may enhance initial self-efficacy and is consistent with
Bandura’s (8) initial tenets.
While mastery experiences are considered essential for improving control, social modeling (by people
similar to the client) may also be important. The principle underlying this approach is to gain self-efficacy via
vicarious learning. In the absence of personal experience, people look to similar others in order to gain
information about whether a behavior is controllable (73). Thus, it may be important to ensure that
participants see others successfully engaged in the target activity. This might be achieved through videotapes,
demonstrations, or by having the participants themselves model the activity. The challenge for the physical
activity promoter is to have modeling relevant to the client. Trainers often do not resemble the demographics
and experiences of their clients, so choosing locations and times with others who are similar to the client
becomes critical.
The principal strategy that underlies the enhancement of self-efficacy through verbal persuasion is that
participants are provided with considerable information about the “why,” “what,” and “where” of physical
activity. This might be achieved through orientation sessions, pamphlets, articles, newsletters, and so on, or
through media presentations (e.g., videotapes, television, newspapers). Information about the ease of
performing certain physical activities may help build positive intentions in the short term. A concentration on
the affective benefits of physical activity, similar to that recommended in improving expected outcomes may
also benefit short- and long-term control perceptions. Convincing evidence is available to show that people
who do not feel confident in their performance of a task subsequently perceive it as less enjoyable (63,87).
Methods described earlier for increasing positive affective experiences with exercise are equally applicable here.
Finally, the principal strategy underlying the enhancement of self-efficacy through physiological states is
ensuring that participants understand the body’s response to activity. Physical activity produces increases in
heart rate and sweating, for example. The meaning the individual attaches to those physiological changes is
important. Individuals who are frequently active expect and understand the body’s response to a physical load.
Participants new to physical activity may not. Therefore, they must be helped to interpret what the
physiological changes mean and how those physiological responses to activity changes with training.
Educating beginners about the normal physiological consequences of exercise, post-exercise soreness, and the
recovery timeline should help clients understand their body states and build their confidence around what can
be expected from an exercise program.
TAKE-HOME MESSAGE
In summary, control over the act of physical activity is an extremely well-validated correlate of intention
and a construct that resides in most theories of human motivation. Shaping the act in achievable bouts
that successively move toward a larger behavioral repertoire (i.e., small, achievable steps) is considered
the best strategy to improving a sense of control. Short-term improvements in control may also be
fostered by displays of similar others performing physical activity and information that attempts to
persuade the client about the ease of the act. Finally, consideration of the affective properties (feeling
states of physical activity) and education about some of the short-term negative body states, such as
muscle soreness, should improve assessments of behavioral control.
While control over the act of physical activity may be important to fostering intentions, maintaining
intention in the face of challenges and barriers over the long-term also requires an improved sense of
control. Developing self-regulation skills is critical to developing perceived control over exercise,
especially in translating positive intention into action and for long-term adherence. As such, these skills
are described in the next section.
TRANSLATING INTENTIONS INTO ACTION
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Most of our established theories used to aid in physical activity promotion and adherence have their main
focus on the antecedents of intention. As demonstrated earlier, a robust level of evidence is present to suggest
that building upon expected outcomes of the behavior and control over physical activity will result in increased
intention. More recently, theories are being proposed to suggest that the translation of intention into behavior
needs the same attention as building those initially strong intentions (53,54,97,126). Overall, these approaches
suggest that behavior change from strong intentions depends primarily on self-regulatory skills, followed by
partial automaticity of the act, environmental support for exercise, and the reduction of cross-behavioral
conflict. The following subsections outline these factors and provide suggestions for successful intention
translation.
Self-Regulatory Skills
According to Bandura’s Social Cognitive Theory, self-regulation is defined as the strategies that an individual
uses to regulate his or her goal-directed behavior or performance (9,12). A critical piece of goal-directed self-
regulation is “the attempt to reduce discrepancies between current states and desired end states” (61, p. 1281).
Although the term self-regulation is typically used to describe how a person regulates his or her own behavior
when pursuing conscious intents or goals (e.g., to lose 10 pounds), it can also occur outside of conscious
awareness or “active” regulation on the part of that individual (e.g., being surrounded with people who value
physical activity and healthy living, 18,45). In other words, the environment, including the people
surrounding the client, is also a strong shaper of his or her physical activity behaviors.
When working with clients to help them build the skills to facilitate their translating their intentions to
become physically active into action, targeting self-regulatory skills is an excellent place to begin. Interventions
targeting self-regulatory skills are among the most frequently used in the domain of physical activity behavior
change and they also have the most convincing research support for their effectiveness in changing exercise
behavior of all behavioral interventions (55,117,135).
Self-regulatory skills include, but are not limited to, goal setting, planning, and self-monitoring (84). Self-
regulation can also involve skills such as enlisting the support of others and creating environmental support to
promote physical activity behaviors. The following section will provide health and fitness professionals with
the necessary tools to help their clients build skills in goal setting, planning, and self-monitoring. Building
these skills with clients is an important step in helping clients translate their intention into action and to adopt
and maintain a healthy lifestyle. There are many curricula available for both youth and adults—using these
self-management skills—and research to support them. See “fitness for life” among others.
Goal Setting and Planning

Goal setting is a process by which an individual evaluates his or her current state or performance, creates a
goal (i.e., what the individual is aiming to achieve; the desired end state), and outlines the actions to be taken
to reach that goal, 74,75,76–78,80,123). Goals can be described in terms of their properties:
1. difficulty (i.e., difficult goals require more effort to be achieved)
2. specificity (i.e., goals can vary on a continuum of specific to vague; specific goals are clearly defined, have a
narrow focus, and outline the type and effort required to realize the goal)
3. proximity (i.e., short vs. long term, 78,123)
Goals can also be considered process (i.e., focused on the behavior being conducted, such as jogging for 30
minutes, three times weekly) and outcome (i.e., focused on the end result of a behavior such as weight loss).
Setting achievable, process-focused short-term goals fosters feelings of control more so than equally achievable
long-term goals due to the frequency of feedback or cues regarding competence (13). Process-focused short-
term goals are also valuable to avoid setting clients up for failure or disappointment by focusing only on long-
term goals. Moreover, Shilts et al. (123) suggest that setting short-term goals rather than long-term goals
mobilizes energy, while setting long-term goals may help with keeping the big picture in mind but they
increase the likelihood of postponing efforts. Short-term goals can be used as one method of helping achieve
long-term goals (13,75,80,125). Goal setting using the SMART framework is a popular approach to self-
regulation (74,76,123) that incorporates many of the important properties of goal setting described earlier.
SMART goals are specific (S; when, where, how, what), measurable (M; quantifiable), achievable/realistic
(AR), and include time frame considerations (T).
Other important considerations when helping clients with their physical activity goals and plans are
persistence (i.e., “the tenacity people show in their endeavors to overcome difficulties and master challenges”
(3, p. 285)) and commitment to change (i.e., “the degree to which the individual is attached to the goal,
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considers it significant or important, is determined to reach it, and keeps at it in the face of setbacks and
obstacles (71)). People have a tendency to set goals that they perceive as both desirable and feasible; however,
this perception does not guarantee commitment to the goals (15). One means to enhance commitment is
creating and signing an exercise contract, which serves to hold the individual accountable and is a visual
reminder (i.e., an extrinsic motivator) of the goal and required behavioral response (25,80). The exercise
contract (i.e., contingency contract, behavioral contract) should include the exercise (frequency, intensity,
time, and type) the individual is committing to, how success (or lack thereof) will be measured, the
consequences of not meeting the goal, and a reward (positive reinforcer) for successful completion of the
desired behavior.
An individual must not only set desirable and feasible goals, but must also actively strive to achieve these
strategies’ goals in the face of challenges by employing effective coping responses. Goal setting is not sufficient
on its own: In the absence of careful planning, many goals fail to be achieved (3). The distinction between two
types of planning relevant to translating initial intentions into action can be made: action planning and coping
planning (126,127). Action planning is a plan aimed at performing goal-directed behavior that specifies the
when, where, and how to turn intention into action.
Coping planning, in contrast to action planning, involves anticipating and managing the risky situations
associated with performing undesired behaviors and overcoming barriers to translating the intention into
action by using effective coping responses (80,126,127). Coping planning is thought important not only in
translating initial intentions into action, but also in maintaining long-term behavior change. Problem solving
and substituting alternatives are coping responses that can be employed to manage risky situations. Problem
solving is a means of brainstorming solutions to problems that may arise. The IDEA approach is a simple
problem-solving framework that can be used to generate a solution to a problem behavior or barrier. The
IDEA approach to problem solving involves:
1. Identifying a barrier to being active (I).
2. Developing a list of creative solutions (D).
3. Evaluating the solutions by choosing a solution and determining how the solution will be carried out (E).
4. Analyzing how well the plan worked and revising when necessary (A; 85).
Substituting alternatives involves brainstorming alternative options for achieving a goal, evaluating the
advantages and disadvantages associated with each method of reaching one’s goal, and then choosing the
option that is most likely to lead to successful behavior change.
BEST PRACTICE STRATEGIES

Evidence for the use of goal setting strategies for fostering physical activity and dietary behavior change with
adults is moderate (69,123); however, there is a need for further research to establish the efficacy with children
and adolescents (123). Research has consistently demonstrated that setting goals that are specific, concrete,
and challenging rather than vague and easy to achieve results in better performance (71,77). A meta-analytic
review of the domain of sports and exercise found that short-term and combined short-term and long-term
goals are more effective than long-term goals alone (69). Research has also demonstrated that
tenacity/persistence is a good predictor of goal attainment (3). Moreover, when commitment to goals is high,
individuals are more likely to act in accordance with their goals than when their commitment to goals is low
(71). In one study, frequency of goal setting, which may reflect a higher commitment to behavior change goals
or possibly may reflect more provision of feedback/cues regarding performance, was found to be positively
associated with use of behavioral strategies for physical behavioral change (91). To assist in goal setting with
your client, you can use the goal setting worksheet provided in From the Practical Toolbox 3.3.
In the domain of physical activity research, convincing evidence continues to emerge that planning is
critical to translating intention into action (e.g., 7,28,81,121,143). However, research also suggests that
intention moderates the planning-behavior relationship, such that an individual with high intention is more
likely to act on their plans than an individual with low intention (121,142). Evidence also supports the idea
that action coping is more important at early stages of behavior change; whereas, coping planning is more
important for adherence to behavior change (121,127). Moreover, accumulating evidence suggests planning
interventions that include coping planning or both coping and action planning are effective in promoting
adherence to health behavior change (6,126,144). In addition, in a recent meta-analysis, action planning was
associated with increases in both self-efficacy and physical activity (143). It has also been found that people
with higher self-efficacy benefit more from planning interventions than individuals who lack self-efficacy (81).
A planning worksheet outlining how to make effective action and coping plans is provided in From the
Practical Toolbox 3.4.
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Self-Monitoring and Feedback
Self-monitoring refers to “paying attention to one’s own thoughts, feelings, and behaviors, and gauging them
against a standard” (80, p.154). Self-monitoring, typically through activity logs or journals (see the self-
monitoring worksheet in From the Practical Toolbox 3.6), is an excellent way of keeping record of the
dimensions of physical activity (frequency, intensity, type, time) and the context of physical activity behavior.
Self-monitoring is a means to increase the client’s awareness of their physical activity, the cues and
consequences of the behavior, and the barriers standing in the way of successfully engaging in the desired
behavior (25). It also provides the individual with feedback about their progress and may increase the
individual’s confidence in their ability to be active. According to goal setting theory, feedback regarding
progress toward a goal is key to effective goal setting (77). Comprehensive psychological and exercise testing
can also serve as a useful baseline for setting goals, monitoring progress/movement toward goals, and for
evaluating and revising goals and the plans implemented to reach those goals (24). A more affordable tool is
the pedometer/step counters, which also allows for goal setting, self-monitoring, and feedback. Ample
research has shown that physical activity interventions that include self-monitoring are more effective in
changing physical activity behavior than those that do not include self-monitoring (31,32,88).
Although behavior change from strong intentions depends primarily on the self-regulatory skills discussed
earlier, there is emerging evidence that partial automaticity of the act, environmental and social support for
exercise, and the reduction of cross-behavioral conflict also play a role. These concepts and preliminary
evidence are presented next.
Automaticity
The automaticity construct has been controversial in human behavior models for almost 40 years (132), but its
utility in predicting exercise has been established (49). Automaticity, in this context, refers to the performance
of physical activity behavior without decision or formal thought. This automaticity is thought to develop from
decisional/intended behaviors that were once conscious and motivation-based, but now are partially acted
upon through environmental cues (1,2,137–139). Thus, automaticity is not random, thoughtless, action.
Instead, automaticity develops from repeated, practiced, and highly motivated actions. The best example of
automaticity may be in cases of driving behavior. Many people can drive to work and home without thinking
about it. The behavior has become so practiced that it is essentially automatic. Indeed, when we attempt to
alter this route—say to go to a store on the way home—we sometimes find ourselves home even though our
initial intention was to stop at a different destination first! Certainly, in the case of physical activity, we are not
suggesting that we want to build skills that create exercise robots (82); however, it does stand to reason that an
efficient physical activity routine that can be performed without a constant motivational struggle is highly
desirable. Based on prior theorizing and research (37,110), it has been shown that those who can act without
conscious deliberation or rumination increase their chances in translating intentions into behavior. For
example, it is proposed that someone who is so used to an exercise routine that they begin the act without
deliberation via simple cues has a much better chance of action control than a person who has to engage in
self-talk, planning, and decision making to act each time (139).
Automaticity is thought to be affected by prior history with the behavior and occur with behaviors that are
highly practiced (14). Therefore, individuals with a more meager exercise history are proposed as at-risk for
having low automaticity when initiating an intention into behavior. While prior physical activity experience
may be an intractable determinate, skill building and prescriptions that involve exercise repetition in terms of
time, acts, location, and other characteristics may help in habit formation (70). Another intervention with
considerable utility to automaticity formation may be planning via implementation intentions (53).
Implementation intentions, the act of setting plans about where, when, how, and what behaviors will be
performed, are proposed to partially act as mini mental links between the behavior and environmental cues
(53,54). It has been proposed and supported by research that implementation intentions may foster
automaticity (54).
Environmental and Social Support

While we intend to make desirable changes like adopting regular physical activity, sometimes we need help to
realize the goal. In this capacity, when one views exercise as a means for maintaining or improving friendships
over the long term, it increases the likelihood that exercise outcome expectations are strengthened beyond our
own individual goals. Similarly, other social outcomes such as building a sense of commitment or
responsibility have shown supportive findings. Research on social affiliation among friends/partners (130),
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children (29,56), and even dogs (23,36,59) has supported this conjecture. Therefore, it is recommended that
social interventions should focus on the broader social exchange and social meaning behind the regular
physical activity if possible.
The enjoyment and distractions from exertion or monotony caused by exercising with others may also aid in
translating strong intentions into behavior (113). If the exercise experience can fulfill socialization (38), it
should strengthen the expectations of the experience (30,44,47). Opportunities to socialize during exercise
also provide a type of multitasking by combining social needs and personal health and wellness needs (38). In
this sense, it can increase the opportunities to act on exercise because one can combine these objectives within
a single act. Relatedly, organizing times to exercise with someone introduces a sense of accountability toward
the other person. Also, social support, specifically the tangible aid from others so one can create time to
exercise (35,115), is a likely influence on the opportunity to act. Others who can free up time by helping with
daily chores will increase the time available to exercise and make it easier to translate intentions into behavior
(30,44,47). Health and fitness professionals can also serve as a means of social support, especially at the outset
of a program, by providing their clients with verbal support and encouragement. This support may increase
their client’s motivation and confidence in their ability to initiate physical activity.
Adjustments to the environment around people with the intention to change may also help. A focus on
improving a client’s opportunities for physical activity needs to be considered. Specific characteristics of the
environment, such as proximity to facilities, serve as cues to action that facilitates or inhibits successful
intention translation. This effect has been demonstrated consistently in past research (95,105,108). This
probably aids in the ease of access of performing physical activity and helps shrink the distance between initial
intentions and the time to act.
Cross-Behavioral Conflict
The successful translation of good intentions into a behavior may be determined, in part, by the amount of
motivation and commitment one has placed on other leisure-time pursuits. This cross-behavioral conflict
serves to thwart physical activity by acting as a negative determinant. The basis for this determinant resides in
the concept of time displacement (101), whereby motivation and planning for other behaviors compete in the
behavioral choices made during free time. Specifically, under the limits of free time, investments of time spent
on one behavior may affect the time that can be spent on another behavior. In this capacity, one behavior can
impede another. Cross-behavioral conflict has been validated in physical activity (50,51,94,100–02,120) and it
is a central tenet of a theory known as behavioral economic theory (140). Television viewing, due to its high
prevalence, is the most noteworthy candidate as a cross-behavioral regulation that may thwart physical
activity, but any leisure-time activity other than exercise can serve in the capacity.
In order to build the skills to decrease cross-behavioral conflict, it is suggested that increasing the
knowledge base about the detriments of prolonged sedentary behavior and lowering ease/ability and
scheduling/planning of these behaviors would be of benefit (100). For example, in the context of TV viewing
behavior, an intervention should focus on educating clients about the health risks of continuous sitting and
public health guidelines around anti-sedentary behavior. Lessening the ease of access (e.g., removal of multiple
TVs, removal of cable), and opportunity (e.g., by keeping a schedule of very specific viewing times when it is
less convenient to do other activities such as 9–10:30 pm) may also be effective. Another means of reducing
sedentary behavior involves educating and having clients consider ways to accumulate active lifestyle activities
into their daily routine (e.g., climbing stairs instead of the escalator, walking to work/nearby store), rather than
scheduling a session of continuous exercise (e.g., strength training at the gym). Incorporating competing
activities such as exercising while watching TV may also be a strategy to increase exercise without asking the
client to give up things they like and does not require extra time in the day. Early research in these sedentary
reduction behaviors has shown success with these strategies (39).
TAKE-HOME MESSAGE
In summary, to facilitate a client’s initial intentions to be physical active, it is essential that the fitness
and health professional help their clients be active in their exercise prescription. The exercise
professional should aim to facilitate the self-regulatory process for the client but not to simply create the
self-regulatory plan for them. The development of the client’s self-regulation skills and toolbox is more
important than the plan itself because goals and plans change over time and life context. Further, a plan
created for the client without their input and collaboration will not result in adherence to an exercise
program and is typically no different than the absence of a plan (16). The preceding section suggested
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that building skills for goal setting, self-monitoring, and planning are crucial to self-regulation, with the
additional consideration of automaticity, social and environmental support, and lowering cross-
behavioral conflict.
To assist you in selecting strategies for use with your clients, the next section provides step-by-step
instructions and worksheets demonstrating how to implement these approaches. For ways to model the
appropriate selection of strategies and tools to implement with your client, see Table 3.2 and, at the end
of this chapter, several sample case scenarios.
STEP-BY-STEP
Follow these steps to implement the approaches discussed in the previous section:
1. Conduct a brief informal interview with your new client and establish rapport (see Chapter 5).
2. Get to know who your client is and what is important to them, as well as their history related to physical
activity, fitness, and health and wellness (see Chapter 2).
3. Determine where your client lies on the intention behavior continuum. Are they…
• Low intent? High intent?
• Having difficulty translating their intention into action?
• Having difficulty adhering over the long term?
Take a look at Case Scenarios 3.1, 3.2, and 3.3 for examples of clients who vary on the intention behavior
continuum.
4. Based on your answers to Step 2, prioritize which physical activity skills building activities you will need
to work through with your client. Possible worksheets to choose from include the:
• Behavioral palate worksheet (see From the Practical Toolbox 3.1)
• Decisional balance worksheet (see From the Practical Toolbox 3.2)
• Goal setting worksheet (see From the Practical Toolbox 3.3)
• Planning worksheet (see From the Practical Toolbox 3.4)
• Exercise contract (see From the Practical Toolbox 3.5)
• Self-monitoring worksheet (see From the Practical Toolbox 3.6)
For guidance in choosing appropriate worksheets for your clients, use Table 3.2, Decision Tree for
Choices of Worksheets and Strategies. The decision tree provides appropriate strategy and worksheet
selection for Case Scenarios 3.1, 3.2, and 3.3. For a client who has low intention or is resistant to
engaging in exercise (Case Scenario 3.1x), appropriate tools include the behavioral palate worksheet, the
decisional balance worksheet, and the planning worksheet (focusing on Step 1: Action Planning).
Additional strategies appropriate for a client who has little intention for exercising include reviewing the
benefits of exercise with an emphasis on the affective experience (e.g., enjoyment, improved mood) or
creating contingency structures (e.g., creating rewards for engaging in physical activity). See Table 3.2 for
solutions to the other sample scenarios.
5. Work collaboratively with your client on the selected worksheets. Notice that each worksheet includes
steps and instructions for you to work through with your clients.
6. Sign an exercise contract based on the activities developed from the worksheets to help increase
commitment to the exercise (see the sample exercise contract in From the Practical Toolbox 3.5).
7. Monitor progress using the self-monitoring worksheet (see From the Practical Toolbox 3.6).
8. Schedule regular follow-ups to evaluate progress, and revise program and sign new exercise contracts
when necessary.
Case Scenario 3.1
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Tony Wear/Shutterstock.com
LOW INTENTION TO EXERCISE; HIGH RESISTANCE

Paul is a 50-year-old overweight man who has never been interested in his health and fitness. He has
always been naturally slim and has never regularly engaged in a physical activity routine. However, in
recent years he has put on considerable weight. He has fallen into a sedentary lifestyle. During his
nonworking hours, he and his wife spend their time eating large unhealthy meals, watching television,
and surfing the Web. His wife has recently taken an interest in their health as a couple, feels frustrated
by their unhealthy routine, and has been pushing Paul to engage in a healthier lifestyle. In pursuit of this
goal, his wife decided to buy them both gym memberships and personal training sessions with you for a
Christmas present. She is determined to start living a healthy lifestyle and to age successfully; however,
Paul is resistant to change and quite anxious about becoming active and finding his way around the gym.
He complains that he is already tired after work and has no interest in getting hot, sweaty, and
experiencing discomfort and muscle soreness.
Case Scenario 3.2
Felix Mizioznikov/Shutterstock.com
HIGH INTENTION TO EXERCISE: “LOST IN TRANSLATION”

Andrea is a 25-year-old woman with two young children aged 3 and 5 years of age. She works full time
in an administrative position for the government, while her husband works long, irregular hours as a
manager in the restaurant business. She was active in her youth, when physical education was mandatory
and her parents had her enrolled in several extracurricular sports after school. She has found it very
difficult to focus on her physical activity and fitness level after having children and returning to work.
Although she is highly motivated to get active and stay healthy so she can keep up and have fun with
her kids, she is having trouble translating her intention into practice. Without the structure provided by
school and her parents and the demands of working and parenthood, she feels lost and has no idea
where to begin. She recently signed up for the corporate gym membership at the local gym. She has
come to you with a strong desire to become active and is looking for guidance on how to adopt a
healthier lifestyle.
Case Scenario 3.3
90
INTENTION BUT NO SUCCESS: STRUGGLES IN LIMBO

Cameron is a 35-year-old who recently graduated from Law school and got hired on at a major law
firm. He is trying to make a good name for himself, and work is a high priority. He has been putting in
long hours at work, is experiencing high levels of stress, his mood is poor, and he is having trouble
sleeping. He makes time for physical activity infrequently and often cancels workouts for work
engagements. Although he grew up in a household that valued health and physical activity and he
played on many sports teams throughout his elementary and secondary school years, this is not the first
time he has fallen off track. He first had difficulty engaging in regular physical activity when he went
away to college at 19 years of age. He recalls being highly motivated to keep physically active when he
was away at school, and intended on going to the gym regularly. He even joined a volleyball team for his
first semester. During his first few weeks of school, he kept to his intention to be physically active, but
then things began to unravel. He had considerable difficulty balancing his heavy course load and study
schedule with his social life. He quit his recreational volleyball team in the first semester of school and
he put on the “frosh fifteen.” He is beginning to see a pattern and has come to you for help to break it
and learn how to maintain a healthy lifestyle in the long term.
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Promoting the adoption and maintenance of regular exercise is undoubtedly a significant behavior
change challenge. A mere 30% of adults are exercising in accordance with the current American College
of Sports Medicine guidelines (2), and nearly 40% engage in no leisure-time physical activity (6). The
question is: What can motivate people to exercise?
The answer depends in part on where they start: Often, what motivates people to begin thinking
about starting to exercise is different than what motivates them to actually begin, which in turn differs
from what motivates them to continue once they are exercising regularly. For those reasons, ACSM (2)
reports that effective exercise interventions are often individually tailored on constructs from a health
behavior change theory and incorporate behavioral strategies such as goal setting, social support, and
relapse prevention.
EVIDENCE: THE TRANSTHEORETICAL MODEL OF BEHAVIOR CHANGE

(TTM)
The Transtheoretical Model of Behavior Change (TTM), also known as the Stages of Change model, is one
of the most commonly employed health behavior change theories within exercise interventions (20,23).
Reviews of interventions matched to individuals’ readiness to change (13,22) have demonstrated that tailoring
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messages is an extremely effective way to change behavior. Furthermore, multiple studies (5,9,12,14–19,32)
revealed that tailored, TTM-based exercise interventions, including those delivered by health coaches (27),
increase the adoption and maintenance of regular exercise. The success of these interventions underscore an
important lesson for fitness professionals: It is crucial to assess each client’s readiness to engage in regular
exercise and tailor your interventions to his or her stage of change. Recognizing the unique needs of
individuals in early stages and reconceptualizing progress as movement to the next stage can significantly
increase the impact of your work with a client. Given the utility of the TTM for assisting clients in adopting
and maintaining regular exercise, this chapter will provide an overview of the TTM and illustrate its practical
application to assisting individuals in adopting and maintaining regular exercise.
The Five TTM Stages

The TTM conceptualizes change as a process that unfolds over time in a series of five stages of readiness to
change (see Figure 4.1).
PRECONTEMPLATION
Precontemplation is the stage of change in which individuals are not intending to exercise regularly in the
foreseeable future (typically defined as the next 6 months). Individuals in this stage are often unaware or
under-aware of the benefits of adopting exercise and overestimating the costs of changing. They are often
characterized by one or more of the three Ds: defensiveness, denial, or demoralization. Often they are
described by the health professionals with whom they interact as nonadherent, unmotivated, or difficult. It is
important, however, not to confuse lack of readiness to adopt exercise with lack of desire to exercise:
Individuals in Precontemplation may want to begin exercising regularly or wish they would, but are not ready
to do so because of perceived barriers, have low self-efficacy (i.e., confidence—or the belief that they can
engage in regular exercise), or lack of information on how to get started.
FIGURE 4.1. Stages of change.
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CONTEMPLATION
Individuals in Contemplation are intending to exercise regularly within the next 6 months. They are more
aware of the numerous benefits of exercise, but are also acutely aware of the cons, or drawbacks. As a result,
they may be ambivalent about exercise. At times, the ambivalence is so profound that individuals get “stuck”
in Contemplation, which is referred to as “chronic Contemplation.” These individuals often lack the
confidence and commitment they need to adopt regular exercise.
PREPARATION
Individuals in Preparation are ready to exercise regularly in the next 30 days and have often taken some steps
closer to their goal, such as exercising on some days or exercising less than 30 minutes per day. They are
creating a plan for how to move forward and are the perfect candidates for traditional messaging and programs
that encourage people to take action to exercise regularly (e.g., Just Do It!). They are also more committed and
confident about their ability to exercise regularly.
ACTION
Individuals in Action have adopted regular exercise within the past six months and are actively using behavioral
strategies to create a new habit. They are likely to experience a setback when they experience a challenge (e.g.,
bad weather, injuries, schedule conflicts) unless they have planned ahead.
MAINTENANCE
Individuals in Maintenance have been exercising regularly for quite some time (typically defined as more than
six months) and are significantly more confident about their ability to maintain the behavior change. Recent
research indicates that low confidence or self-efficacy is the single best predictor of discontinuing exercise
while in the Maintenance stage (11).
Moving Individuals Forward in the Stages of Change

As will be illustrated in the following text, an individual’s stage of change has important implications for
selecting intervention strategies and messaging. Equally important, though, are the implications the stage
paradigm has for reconceptualizing what “success” means in working with clients to help them adopt or
maintain exercise. A reasonable goal for each client is to help them move forward one stage of change, as
forward stage movement is an important predictor of later success. In fact, assisting individuals in moving
forward at least one stage of change (e.g., from Precontemplation to Contemplation) can as much as double
the probability that they will take effective action in the following 6 months. Helping them move two stages
can triple their chances of taking action (29). How can you help clients achieve that goal? By encouraging
them to use behavior change strategies matched to their stage of change.
Those strategies are derived from other behavior change constructs included in the TTM, such as
decisional balance, self-efficacy, and the 10 processes of change.
PROS (BENEFITS) AND CONS (DRAWBACKS)

Decisional balance represents an individual’s relative weighting of the pros (i.e., benefits) and cons (i.e.,
hassles, barriers, or drawbacks) of changing (31). An extensive review of the pros and cons for 48 health
behaviors (10) revealed a consistent pattern of the pros and cons across the stages for 48 health behaviors. The
cons are higher than the pros in the Precontemplation stage, while the pros outweigh the cons in the Action
stage. The relationship between the pros and cons across the stages has important implications for
intervention strategies. The key takeaway messages for fitness professionals and other health care providers are
that:
1. Raising the pros is twice as important as reducing the cons.
2. It is crucial to raise the pros for individuals in the early stages.
3. Contemplation is the time to begin addressing the barriers.
SELF-EFFICACY
Self-efficacy is defined as an individual’s belief about his or her ability to do or achieve a specific behavior (3).
Within TTM-based exercise interventions, it is operationalized as confidence to make and sustain changes.
Confidence is low in the Precontemplation stage and increases across the stages (8). Given the importance of
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self-efficacy, it needs to be raised early by assisting individuals in setting and achieving small goals that will
build their confidence for taking on increasingly difficult challenges. If, for example, someone is not exercising
at all but is intending to do so in the next 6 months, it would be helpful to have them set a reasonable and
achievable goal to begin exercising slowly (e.g., 10 minutes, three times a week) and increase the frequency and
intensity once that goal has been mastered.
THE PROCESSES OF CHANGE

The processes of change (25;26) (see Table 4.1) represent both the covert and overt behavior change strategies
that individuals use to progress through the stages of change (26). Research demonstrates that experiential
(i.e., cognitive, affective, and evaluative) processes of change are typically emphasized by individuals in the
earlier stages, whereas individuals in later stages rely more on the behavioral processes (i.e., social support,
commitments, and behavior management techniques) (28). Additional research demonstrates that process use
differs significantly across the stages of change for exercise (4,18,21,30,33). Each process can be activated by
various techniques. Consciousness raising, for example, can be accomplished by reading articles or listening to
news stories about the importance of exercise, talking with a health care provider or trainer about what modes
of exercise best suit a person given their health history and physical limitations (if any), asking friends what
types of exercises they enjoy, checking out the website of a local gym or fitness facility to see what types of
programs they offer, or keeping a diary (paper or a mobile app) of how much physical activity a person is
getting during the week. The first column of Table 4.1 includes both the official and (parenthetically) a more
informal name of each process of change. Figure 4.2 illustrates the stages in which various processes of change
are most relevant.
TABLE 4.1 Processes of Change
Processes of Change Description Strategy Examples

Experiential Processes
Consciousness Learning new facts, ideas, and tips that Read books, magazines, or visit Web sites that
Raising (Become support exercise focus on exercise and health.
Informed)
Dramatic Relief (Pay Experiencing negative emotions (fear, Think about somebody close to you that has
Attention to anxiety) that go along with the health had severe health problems that may have
Feelings) consequences of not exercising or the been prevented by regularly exercising. Does
positive emotions (e.g., inspiration) that go their inactivity and subsequent health problem
along with regular exercise upset you?
Environmental Realizing the negative impact not exercising Consider the example your inactivity sets for
Reevaluation (Notice has on others and our society—and the your children, family, friends, and coworkers.
your Effect on positive impact that exercising could have
Others)
Self-Reevaluation Realizing that regular exercise is an Ask yourself, “How do I think and feel about
(Create a New Self- important part of one’s identity myself as someone who is not exercising
Image) regularly? How might I feel differently if I was
exercising regularly?”
Social Liberation Realizing that social norms are changing to Name some social changes that support
(Notice Social support exercise exercise (e.g., walking paths).
Trends)
Behavioral Processes
Self-Liberation Believing in one’s ability to exercise regularly Set a date to start exercising regularly and tell
(Make a and making a commitment to change based your friends, family, and coworkers your plan.
Commitment) on that belief
Helping Seeking and using social support to start Join an adult sports league or ask a friend to
Relationships (Get and/or continue exercising walk around the neighborhood with you every
Support) evening after dinner.
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Counterconditioning Substituting healthy alternative behaviors Ride your bike to work instead of driving your
(Use Substitutes) and thoughts for unhealthy ones car.
Reinforcement Increasing the intrinsic and extrinsic rewards Buy a new set of workout clothes after you
Management (Use for exercise and decreasing the rewards for have met an exercise goal.
Rewards) being sedentary
Stimulus Control Removing reminders or cues to be sedentary Leave your running shoes and clothes in a bag
(Manage your and using cues to exercise by the door to remind you to run during your
Environment) lunch break.
FIGURE 4.2. Processes by stage of change.
Step-by-Step
The basic assumption of traditional action-oriented interventions is that everyone is ready to change. The
stage paradigm, however, operates under a fundamentally different assumption—that the majority of
individuals are not ready to change. This difference in perspective allows exercise professionals to assist clients
in employing the most effective strategies at the right time to help them get ready to initiate and maintain an
exercise routine. Thus, encouraging the use of specific processes at the appropriate time facilitates forward
stage movement.
1. Step 1. Assess Readiness to Change: Matching the intervention program or message to the needs of your
client increases the likelihood that she or he will successfully adopt and maintain regular exercise. To
begin, you will first need to assess how ready each client is to exercise to guidelines (i.e., in accordance
with the ACSM guidelines for 30 minutes per day on 5 or more days per week of moderate exercise, or
20 minutes on 3 or more days per week of vigorous exercise, or some combination (2). It is crucial to
know how ready he or she is to meet the public health recommendation, which is the ultimate goal. If a
client has physical limitations that prevent him or her from achieving that level of exercise, you can assess
readiness to engage in whatever level of physical activity is safe for them based on their health care
provider’s recommendations. You can separately assess readiness to engage in resistance exercises for each
major muscle group and neuromotor exercise 2 to 3 days per week or flexibility exercises on at least 2 to 3
days per week (1).
2. Step 2. Target Interventions to Individual’s Readiness to Change: Once you have assessed each
individual’s readiness to exercise regularly, you can employ the suggestions on the following pages to
assist them in moving to the next stage. If, for example, your client is in the Contemplation stage, you
can employ the intervention strategies described in the Contemplation section. We’ve also provided
sample activities you can use with clients in each stage (25). These activities are handouts for the client,
so they are written as if the client is reading them. For more guidance about how to apply the TTM
successfully, you can participate in an e-learning module developed by Pro-Change Behavior Systems on
using the TTM for coaching (details at www.prochange.com/e-learning) or refer to Mastering Change, A
Coach’s Guide to Using the Transtheoretical Model with Clients (24).
PRECONTEMPLATION
The goal in Precontemplation is to encourage clients to view success as progress to Contemplation. They are
not ready to take action, so encouraging them to do so is likely to lead to dropout or demoralization.
Providing information is a great way to initiate the behavior change process. Keep in mind that although they
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are not ready to begin exercising regularly, they may be willing to set a small goal (e.g., adding a few minutes
of exercise to their day once a week). If they aren’t ready to set that goal, see if you can arrive at one that feels
reasonable to them.
For a sample Precontemplation activity, see From the Practical Toolbox 4.1.
Precontemplation: Key Intervention Strategies
Increase the Pros

• Encourage clients to list their own “pros” of exercise—How will they benefit from exercising regularly?
What’s in it for them?
• Reinforce what they came up with and point out additional benefits, including some that are specific to
them.
• Provide a list of over 75 benefits.
• Encourage clients to create a Top Ten List of the most personally relevant benefits.
Raise Consciousness—Help Clients Become Informed
• Increase their awareness of consequences of sedentary behavior (e.g., ask their health care provider about
how being sedentary is affecting their health).
• Make observations (e.g., “You’re saying that you have less energy since you stopped exercising…”).
• Encourage the client to be more open to information from media, health care providers, friends, etc.
(e.g., ask them to notice headlines related to exercise).
Social Liberation-Notice Social Trends
• Encourage the client to name some social changes that support exercise; provide examples to add to what
they mention.
• Ask them to notice other social trends that are making it easier to exercise, including:
• Walking paths
• Free or low-cost exercise programs and fitness classes offered through towns or worksite wellness
programs
• Fund-raising groups (e.g., The Leukemia Society’s Team-In-Training) designed to train clients for
exercise while raising money for a great cause
• Increasing opportunities to work out at home (e.g., fitness DVDs from Netflix, video games like
Dance, Dance Revolution, Wii Sports, and Wii Fit)
• Mobile wireless technology is making it easier to work out and track physical activity by downloading
fitness programs and trackers to cell phones or MP3 players (e.g., work out apps such as Nike + or
mapmyrun.com).
Environmental Reevaluation—Notice Your Effect on Others
• Encourage the client to consider the effect of not exercising on others, including children, spouse, friends,
and family.
• Ask if the client is setting the example he or she wants to set for those people.
• Ask whether someone else will have to deal with the potential consequences of their sedentary behavior
(e.g., chronic diseases, physical limitations, early death).
SAMPLE ACTIVITY FOR PRECONTEMPLATORS: RAISE THE PROS

People in Precontemplation usually don’t focus enough on all of the good reasons to exercise
regularly. The more good reasons, or “Pros” you have, the easier it will be to take the next step—
when you are ready.
The following are 75 benefits of exercising regularly.
Which benefits are most important to you? Be sure to check them off as you go.
Exercise will improve your health in many ways:

You will manage your weight better.
You will lower your risk of an early death.
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You will improve your quality of life.
You may lose weight, particularly if you also reduce calories.
You will improve heart, lung, and muscle fitness.
You can reduce your risk of many illnesses:

Coronary heart disease
Diabetes
High blood pressure
Osteoporosis (brittle bones)
Stroke
Depression
Dementia
Diverticulitis
Gallstones
Colon cancer
Breast cancer
Endometrial cancer
Lung cancer
Hip fracture
It’s good for your overall well-being:

Exercise increases your energy.
Regular exercise helps you cope with stress.
Exercising regularly relaxes you.
Regular exercise improves your sleep.
Regular exercise controls your appetite.
Exercising regularly makes you stronger.
Exercise improves your mood.
Exercise increases your endurance.
Exercise can reduce pain.
Exercise can reduce body fat.
It’s good for your heart:

Helps raise levels of “good” cholesterol (HDL)
Decreases levels of “bad” cholesterol (LDL)
Increases your chance of surviving a second heart attack
Decreases risk of clogged blood vessels
Lowers your resting heart rate
Decreases irregular heart rhythms
Improves circulation
It improves your self-image:

Increases confidence
Improves self-esteem
Helps you look better
Improves your posture
Helps you be more productive
Increases your joy in life
Increases your sense of well-being
Improves your self-worth
It improves your overall health:

Helps your immune system work better
Helps your body use insulin
Increases your metabolism
Helps muscles burn more energy all day
Strengthens joints
Makes your bones stronger
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Lowers the risk of erectile dysfunction
Improves bowel regularity
Strengthens muscles
You’ll notice changes in your everyday life:

You’ll feel less nervous or anxious.
You’ll have increased stamina.
You’ll be more alert and focused.
You’ll improve your memory.
You’ll be more flexible.
You’ll become better coordinated.
You’ll help relieve the pain of tension headaches.
You’ll reduce your risk of falling.
You’ll reduce and prevent low back pain.
You’ll have less muscle tension.
You’ll better tolerate heat and cold.
You’ll have increased sex drive and improved sexual performance.
You’ll have fewer illnesses and absences from work.
You can challenge yourself in new and different ways.
You’ll be able to better manage your anger.
You’ll find that exercise takes your mind off other things for a while.
Your balance will improve.
You will function better.
Your clothes may fit better.
Others will benefit, too!

Your loved ones would worry less about your health.
You will set an example about making healthy choices.
You would be a healthy role model for your own children, family, and friends.
© Pro-Change Behavior Systems. Reprinted with permission.
CONTEMPLATION
The goal in Contemplation is to encourage clients to view success as progress to Preparation. They are getting
ready to take action, so encouraging them to rush to adopt regular exercise before they are ready is likely to be
ineffective. The real risk for a Contemplator is that they will get stuck in “chronic” Contemplation because
they are ambivalent. They see the value of adopting regular exercise, but are still acutely aware of the barriers
or drawbacks. To help them keep moving forward, encourage them to take small steps. Being successful with
those small steps will build their confidence and help them see the benefits of exercise more clearly.
For a sample Contemplation activity, see From the Practical Toolbox 4.2.
Contemplation: Key Intervention Strategies
Make the Pros Outweigh the Cons

• Ask client to name his or her most significant con(s).
• Acknowledge changing does have costs, but avoid debate about whether change is “worth it.”
• Ask clients to shrink cons by:
• Comparing them to their growing list of pros.
• Asking how important cons are relative to pros.
• Challenging themselves to overcome the cons.
Consciousness Raising—Become Informed
• Encourage clients to keep an exercise log or wear a pedometer so they can see how much, if any, exercise
they are getting and when.
• Encourage clients to ask questions and search for more information (e.g., explore alternatives for exercise
venues that are well matched to preferences and schedules, talk to friends about how they fit exercise into
their schedule).
• Ask clients what headlines or news stories they have seen recently about exercise (e.g., a story on National
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Public Radio about exercise increasing memory capacity among older adults, etc.) and challenge them to
look for more.
Self-Reevaluation—Create a New Self Image
• Encourage the client to ask him or herself about self-image: “How do I think and feel about myself as
someone who is not exercising regularly?”
• Challenge the client to describe the kind of person he or she wants to be.
• Ask the clients to describe how their self-image might improve if they were exercising regularly.
• Provide a checklist of adjectives for the client to endorse (e.g., energetic, sluggish, fit, out of shape, etc.).
Dramatic Relief—Pay Attention to Feelings
• Ask the client to share an inspirational story about someone they knew who improved their health and
well-being by starting to exercise regularly (a friend, family member, celebrity, etc.).
• If she or he cannot think of an example, share one from your experience—convey the impact of
beginning to exercise on someone who had been in the stage where this client is now.
• Ask the client to describe how she or he would feel if they were diagnosed with a chronic disease like
diabetes or heart disease due in part to an unhealthy lifestyle—would they regret not exercising? Would
she or he be worried about premature death? How can taking small steps toward regular exercise help
him or her deal with those feelings?
• Encourage Small Steps (to Build Self-Efficacy)
• Provide clients with options for a small step they can take toward their goal (e.g., a 10-minute walk
each day, going to one exercise class each week, taking the stairs instead of the elevator, making an
appointment with their health care provider to get clearance to begin exercising).
• Ask clients to choose among the small steps suggested or provide their own examples. Check in with
them again to see how they did.
SAMPLE CONTEMPLATION ACTIVITY: OVERCOME THE ROADBLOCKS

There is a good chance you are wondering whether regular exercise is worth the effort. It can be
challenging to change old habits, especially at first. We have three strategies to help reduce the
drawbacks or roadblocks you might be facing.
Jot down your three biggest roadblocks in the table below. Which of the following strategies will you
use to overcome each barrier?
1. Create a list of the benefits, or pros, of exercising regularly. (The Sample Activity for
Precontemplators: Raise the Pros, found in From the Practical Toolbox 4.1, can be used here, as
well, if you have not already done so.) As you add to your list, the drawbacks, or cons, may seem
less important.
2. Consider the cons as the hassles they are, compared to the serious consequences of not exercising
regularly. For example:
• How does the cost of an exercise class or a new pair of sneakers compare to the risk of diabetes
or heart disease?
• How does finding the time to exercise compare to the time you could be adding to your life by
doing it?
• How does the temporary discomfort of starting to exercise compare to the chance you will have
less strength and endurance over time if you don’t exercise?
3. Counter the cons, or drawbacks, with practical alternatives or challenges. For example:
• If I lack a 30-minute block of time to exercise, I can do three, 10-minute blocks during the day.
• I can watch a favorite show while I am on a treadmill to make the time pass more quickly.
• If I am embarrassed to exercise in front of others, I can exercise at home, go to a class for
beginners, or hit the gym when it is not crowded. I will feel less self-conscious.
• If I cannot afford a gym membership, I can walk outside for free, sign up for a low-cost class at
my community center, or ask if the gym offers a sliding scale membership fee.
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PREPARATION
The goal in Preparation is to encourage clients to be successful when they adopt regular exercise. Help them
set a date, make a concrete plan, and build a support team. Encourage them to anticipate potentially difficult
situations (e.g., travel, upcoming busy times at work, bad weather) and make contingency plans so they do not
get off track. Having a plan will build clients’ confidence that they can achieve their goals. Your
encouragement and support will also be crucial.
For a sample Preparation activity, see From the Practical Toolbox 4.3.
Preparation: Key Intervention Strategies
Self-Liberation—Make a Commitment
• Encourage client to make a strong commitment to start exercising regularly by:
• Setting a specific start date, rather than waiting for a magic moment
• Sharing commitment with others (tell others, post on Facebook or other social networking sites, etc.)
• Creating a specific “Action Plan” and gathering any information they need
• Writing down their commitment, start date, and action plan
Helping Relationships—Get Support
• Ask clients to identify others who can support their change efforts
• A friend trying to make similar change
• Loved ones, family, friends, neighbors, coworkers
• Facebook friends
• You or other staff at their gym, provider’s office, etc.
• Encourage clients to be as specific as possible about the type and amount of support and
encouragement they need.
• Assist client by:
• Role-playing requests for support
• Identifying additional sources of support
• Tapering support if it appears he or she is becoming dependent on you (e.g., by meeting less often).
Self-Reevaluation—Keep Creating a New Self-Image
• Encourage clients to think about how they will think and feel about themselves after they have started
making changes.
• Utilize visualization exercises (i.e., client imagining themselves in 3 to 6 months or a year)
• How they think about themselves
• How their image of themselves has shifted
• How their health has changed
• How their outlook has changed
• Here are some additional guidelines for visualization (6):
• Find a quiet place free of distractions. Relax and take deep breaths.
• Visualize color—first as large blue circles. See them shrink to small dots and then disappear. Blue is a
relaxing color.
• Fill the scene with exercise images. Be as specific and detailed as possible.
• Progressively add specific details including the client seeing themselves in great detail.
• Have the client imagine themselves in the exercise setting. Imagine in detail how regular exercise will
change their self-image. Have the client imagine the tasks and motor skills in vivid detail.
• End by guiding them to breathing deeply, slowly opening their eyes, and adjusting to the real external
environment.
Counterconditioning—Use Substitutes
• Encourage clients to substitute healthy thoughts for unhealthy ones that might hold them back. You can
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share these examples:
• If you are feeling tired, tell yourself how much energy you will have after you exercise.
• “On stressful days, think of exercise as a time away from the day’s worries.”
• “When you think you’re too busy, remind yourself that exercise is an important part of being healthy.”
SAMPLE PREPARATION ACTIVITY: MAKE A COMMITMENT

Before beginning any exercise program, it is important to check with your doctor to make sure he or
she does not have any concerns or recommendations for you.
Once you have gotten the green light, it is full steam ahead.
1. Set a Goal
Choose the specific goal you will work on by checking one of the following boxes.
150 minutes of moderate exercise (at least 30 minutes on at least 5 days per week)
75 minutes of vigorous exercise (at least 20 minutes a day on 3 or more days)
A combination of moderate and vigorous activity that adds up to those targets (assuming 1 minute
of vigorous exercise = 2 minutes of moderate)
8 to 12 repetitions of resistance exercises that include all major muscle groups, 2 to 3 days per week
Exercises to improve balance, coordination, and agility, 2 to 3 days per week
Flexibility exercises (60 seconds per exercise) for each major muscle-tendon group, at least 2 days
per week
2. Find an Exercise
Making exercise a habit is a lot easier if you find something that matches your exercise goals, and
that you really enjoy doing.
The most popular form of exercising in America is walking. However, you may prefer using a
stationary bike, swimming, doing Zumba, taking a fitness class, doing yoga, playing basketball, or
lifting weights.
The key is to think about what you want to gain from exercise, and then find the right type of
exercise for you.
The exercise I choose is: ________________.
3. Set Your Start Date

When will you start to exercise regularly? Studies have shown that it helps to:
• Pick a date in the next month.
• Choose a day that you have some control over.
• Select a day that will not be too stressful.
• Mark your date where you will be reminded (in your planner or phone, etc.).
I will start exercising regularly on:
4. Tell Others about Your Commitment

Public commitments are stronger than private ones. Every time you tell someone about your promise
to start exercising regularly, you make your commitment stronger.
Start to strengthen your determination to exercise by:
• Deciding who you will tell about your commitment, and
• Telling them about your plans. Who will you tell about your plan?
I will tell:
__________________ ________________
__________________ ________________
How will you tell people? Consider these ideas:

• Update your Facebook or Twitter status to: “I am starting an exercise program!”
• Say to your friends, family, and coworkers: “I wanted to let a few people know that I’m planning to
start exercising regularly. Telling people will help me stick with it. I plan to start on ________.
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Look for me at the gym/pool/on the road/walking path!”
• Send an email, text message, or instant message stating: “I am committing to an exercise plan!”
• Put a note on your refrigerator: Exercise plan starts __________!
• Download a smartphone app: Apps like Runkeeper will not only track your workout for you, but
will upload your workouts and results to Facebook or Twitter.
Do not wait! Let as many people as possible know that you are going to be exercising regularly.
5. Make an Action Plan

You will be more successful if you plan your strategy in advance. Be as specific as possible, keeping in
mind how you will tackle any roadblocks that occur. For example, have a backup plan for bad
weather.
To make sure I exercise, I need to: (register for gym classes, pack exercise clothes the night before,
etc.)
Before starting, I need to: (buy new sneakers, get gym schedule, etc.)
What else do I need to get started?
ACTION
The goal in Action is to help the client continue exercising regularly. Encourage them to plan ahead to
prevent slips: Remind them that failing to plan is planning to fail. Having a specific plan to deal with any
potentially difficult situation (e.g., holidays, stressful times at work, gym closures) will keep their confidence
high, which is crucial in Action. At the same time, reassure them if they have a slip that they need not get
discouraged. It is common to slip. Educate them that the most important thing is to evaluate what went
wrong, create a plan for dealing with the situation in the future, and get back on track as quickly as possible.
For a sample Action activity, see From the Practical Toolbox 4.4.
Action: Key Intervention Strategies
Counter Conditioning—Use Substitutes

• Assist clients in replacing negative behaviors with positive behaviors (e.g., “Instead of waiting until the
end of the day to exercise (when I might not get to it), I will exercise in the morning”).
• Teach clients to challenge negative thoughts by substituting positive alternatives (e.g., “Instead of
thinking of exercise as a chore, I will think of it as a gift I give to myself”).
• Problem-solve with clients to identify behavioral alternatives that will work for them.
Stimulus Control—Take Control of Your Environment
• Help the client identify and avoid people, places, and things that increase the likelihood of being
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sedentary (i.e., sitting down to watch “just one” show at night, busy days, friends who do not exercise,
travel) and plans to work around those.
• Encourage clients to use reminders to exercise, like notes, scheduling exercise in their calendar, or signing
up for a class so they have a specific time to exercise.
• Assist clients in identifying ways to restructure their environment to make it easier to exercise regularly
(e.g., exercise at lunch time with coworkers, leave their gym bag and sneakers in the car so they do not
have to go home after work first, etc.).
Helping Relationships—Get Support
• Encourage clients to seek support from others, especially those who are regular exercisers.
• Encourage clients to be as specific as possible about the type and amount of support and encouragement
they need.
• Point out that support can come from professionals as well as personal sources (e.g., trainers, health care
professionals, etc.).
• Remind clients that they may need to adjust their support team over time.
Reinforcement Management—Use Rewards
• Encourage the client to notice the intrinsic rewards of exercising regularly (more energy, lower blood
pressure, more self-confidence, higher self-esteem, higher productivity, etc.).
• Encourage clients to reinforce themselves with positive self-statements.
• Ask the client if they want to use tangible rewards for meeting various short-and long-term goals or
milestones (e.g., new sneakers or workout clothes after 3 months of regular exercise).
Self-Liberation—Make a Commitment
• Encourage the client to reaffirm their commitment to exercising regularly and to believe in his or her
ability to do so.
SAMPLE ACTIVITY FOR ACTION: USE SUBSTITUTES

Replacing old habits and ways of thinking with new ones is one of the secrets to continuing to
exercise regularly. The following examples will show you how others have made healthy substitutes.
Name Old Way of Thinking Healthy Substitute

Paul “I used to get frustrated “Now, I go to the gym early in the morning when it’s
when I got to the gym not so busy. When I can’t do that, I go for a jog
and the machines were outside or do squats, sit-ups, push-ups, lunges, and
taken. So I’d just turn use free weights at home. That way, I’m certain to
around and leave— get a daily workout.”
without exercising.”
Jake “I always found it “I had to schedule a time to exercise to be sure I did
difficult to set aside it. It has worked really well—so now, I treat that
time for exercise time like an appointment. On the rare times when I
because I let all my don’t feel like going, I tell myself that I can go for a
other priorities come few minutes and stop if I want. I’ve never stopped—
first.” once I get moving, I’m fine.”
Danielle “I used to skip “Now I remind myself that exercising is one of the
exercising when I felt best ways to manage my stress. I always feel better
stressed.” after I work out. Plus, it makes me more productive.”
Lila “I used to watch a lot of “Now I tell myself that I can trade one of my half-
TV in the evenings. hour shows for a brisk walk. I read last year that
watching too much TV can actually make you gain
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weight. Watching TV for a half hour burns 36
calories—brisk walking burns about 148.”
Terry “I get bored easily.” “To keep myself interested in exercise, I add variety
to my exercise program. Two days a week I walk, 2
days I swim, and 2 days I use the stair climber or
elliptical machine at the gym. Cross-training has also
given me the confidence to try new things. I feel
stronger overall.”
Now give some thought to the old thoughts and behaviors you might need to replace with
healthier substitutes. Come up with at least one alternative for each.
MAINTENANCE
The goal in Maintenance is to help the client make regular exercise a life-long habit. Assist your clients in
planning ahead to prevent slips in times of unusual distress (major stressors). Encourage them to get back on
track quickly if they happen to have a slip to prevent that slip from turning into a major backslide.
For a sample Maintenance activity, see From the Practical Toolbox 4.5.
Maintenance: Key Intervention Strategies
Stimulus Control—Continue to Control

• Help client identify any people, places, or situations that they need to avoid to stay on track.
• Encourage clients to continue to use reminders to exercise.
• Ask clients if they have restructured their environments enough to ensure that they will keep exercising.
Counterconditioning—Continue to Substitute
• Encourage the client to keep his or her thinking positive (rule of thumb—three positive thoughts for each
negative thought).
• Help clients to plan ahead to deal with difficult situations so confidence is high.
• Remind clients that a majority of relapses occur at times of distress and that although distress cannot be
prevented, relapse can be.
• Remind clients that one of the best stress relievers and mood elevators is exercise. Other alternatives for
dealing with distress include seeking support and using relaxation.
Reinforcement Management—Use Rewards
• Encourage clients to reward themselves for reaching various goals and overcoming any slips they might
have.
Get Support
• Encourage the client to seek support as needed.
• Remind them they can now offer support to others to consolidate their own gains.
Recycling
• Many clients relapse before reaching permanent Maintenance.
• Encourage clients to view setbacks/lapses as an opportunity to learn and move ahead better prepared.
• Encourage the view of a setback as temporary.
• Help clients analyze slips and problem-solve about what can be done differently the next time.
• Encourage clients to maintain an image of who they are working to be and an image of themselves as
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someone who is succeeding in the process.
• Ask clients to reassess their current stage if they slip out of exercising regularly.
SAMPLE MAINTENANCE ACTIVITY: PLAN AHEAD TO KEEP

CONFIDENCE HIGH
Having been a regular exerciser for so long, you’re probably pretty confident in your ability to keep
exercising.
During the coming years, though, you might face new situations that could challenge your
confidence. Read the following stories to learn how others have dealt with difficult situations and
answer the questions that follow each one.
Difficult Situation: Stacey

Stacey had been walking as a way to stay healthy and maintain her weight for just over a year. During
winter, though, she slipped on the ice, fell, and sprained her ankle.
By the time her injury had healed, it was spring. Though there was no ice on the ground, she still
didn’t want to head outside for a walk. She knew she needed to exercise—especially after she tried on
her spring clothes and discovered that they were tight.
It took a while, but one day she just put on her sneakers and went for a walk. “I can’t believe how
good it felt! I don’t know why I waited so long. My body needs this!”
Since then, she’s back to walking regularly, and is feeling better than ever. She’s even been saving
up to buy a treadmill when winter hits. This winter there will be no ice to slip her up!
Imagine that you couldn’t perform your regular exercise. What would you do instead?
Difficult Situation: Brian

Brian has been working toward a promotion at work. He is very good at his job, and has been
putting in extra hours to stay in the race for the position.
He was stressed, feeling like he needed to be there all the time to show his commitment. This
meant he stopped running…for the first time in years. Not running affected Brian pretty quickly. By
the second week, he was less focused, could not sleep well, his stress was building, and he was
grouchy all the time. On the tenth day of his “all work, no play” routine he took a run during lunch.
“When I got back from that run, I had so much more energy and was so focused that I had a really
productive afternoon and evening. It’s easy to take exercise for granted once you’re used to doing it
regularly. But after stopping for a couple of weeks, I realized that getting out for a run helped me
clear my head and stay balanced. I had to keep it up to be able to focus on my work.”
After that, Brian made sure to get a run in every day during lunch, rain, or shine. He had learned a
lesson about moderation—all work and no play is often less productive. And because he showed his
boss he was able to dedicate himself to work in a healthy way, he got the promotion!
Brian discovered that he could not function well without exercising regularly. How would you
function without your regular exercise?
How does exercise help you achieve your goals?
What other unexpected situations could derail you (e.g., extended travel, change in daily routine like
a new longer commute, or change in family demands, such as a sick parent)?
How will you handle those unexpected situations?
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Avoiding Boredom
Maintaining an exercise routine is a daunting task that involves continuously motivating choice in performing
a behavior. Thus, it is not surprising that many individuals often focus on performing one, or only a few,
different types of physical activities when beginning or maintaining an exercise routine. For this and any
number of other potential reasons, people may become bored with their routine. To avoid boredom, you could
encourage your clients to:
• Incorporate a variety of physical activity into their exercise routines
• Keep their usual routine interesting by varying their route
• Change the music they listen to
• Inviting different friends to join them.
The following strategies will also help your client to avoid boredom and relapsing to sedentary behavior. It
will be most helpful to engage in nondirective problem solving with your client to generate solutions for
avoiding boredom using the suggestions that follow. In other words, engage them in an active discussion in
which you are facilitating their creation of a plan to incorporate variety into their routine.
For a sample form for monitoring workouts to avoid boredom, see From the Practical Toolbox 4.6.
Strategies to Avoid Boredom
• Have your client reconceptualize boredom with their current routine as an opportunity rather than a
hindrance. This is a good time to finally attempt a sport, activity class, or new exercise routine that they
have wanted to try.
• Challenge your client to identify what they hope to get out of exercise and to identify what types of
activities could provide that feeling or outcome. If, for example, they want to build strength, they can lift
weights, try white water rafting, or take Zumba. If they want creativity, they can try skateboarding,
snowboarding, freestyle dance, mountain biking, urban hip hop, or inline skating. If they want to build
stamina, they can try hiking, distance running, or swimming, or to boost a mind–body connection they
could try yoga, Tai Chi, Pilates, or martial arts.
• Encourage them to look for helpful information while exploring other types of exercise.
• Help them to internalize their motivation to exercise by focusing on how good it feels to try other forms
of physical activity and experience the sensations of participating in a new physical activity.
• Encourage your client to get help from others. Good examples include joining a new gym, activity group,
recreational sports team, or community recreation league. Encourage them to ask different friends, family
members, and/or coworkers to join them to exercise.
• Recognize that many clients are looking to exercise professionals for this type of helping relationship.
Encourage them to become their own coach by determining what exactly they are bored with in their
routine (e.g., lack of enjoyment; lack of satisfaction with performance/results) and problem-solving
about other ways to achieve the desired outcome.
• Help them to realistically evaluate their goals and expectations. Give them information about which
other activities may help accelerate progress toward appropriate short-, medium-, and long-term goals.
• Have your client track their progress daily. Carefully monitoring all aspects of their workouts allows you
(and them) to see exactly which aspect(s) are contributing to boredom. Be sure to monitor:
• What types of exercise are being performed, and their level of interest while performing it
• Feelings of perceived exertion
• Satisfaction with each workout
• If short-, moderate-, and long-term goals are being met. Are these goals realistic to begin with? Can
they be adjusted?
SAMPLE MONITORING FORM
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Date: ______________________ Location of workout: ________________________________
Did today’s workout keep me on track for my short-term goals? Yes No

Did today’s workout keep me on track for my medium-range goals? Yes No
Did today’s workout keep me on track for my long-term goals? Yes No
How did I feel before today’s workout?
How did I feel during today’s workout?
How did I feel after today’s workout?
Which (if any) parts of my workout could I change to help me stay motivated, enthusiastic, and on
track to accomplish all of my goals?
Any additional notes or comments:
Relapse Prevention
Understanding that slips and setbacks will happen is the first step in not letting those slips derail all of the
hard work an individual has done to become physically active. In terms of exercise, this means avoiding relapse
to sedentary behaviors. Thus, strategies for preventing relapse must focus on addressing the temptations to be
sedentary.
Strategies to Help Avoid Relapse
• Encourage your client to recognize the times when they are tempted to skip a workout. Come up with a
strategy to avoid succumbing to this temptation. For example:
• Get a gym membership or treadmill for the home if they enjoy running, but do not like running
outside in bad weather.
• Call a friend when they are not in the mood to exercise and need a little extra social support to stay on
track.
• Focus on the mood improvements that result from exercising to avoid skipping a workout when they
feel down.
• Assist your client to recognize all of their previous accomplishments, successes, and new knowledge they
have about exercise and health. Help them realize the barriers they have overcome to get where they are
now, and remember the experiences that they had while becoming a regular exerciser.
• Encourage your client to reward themselves for all of their accomplishments. It may seem obvious to
reward behavioral milestones such as working out 4 days in one week, or reaching a new performance
goal, but remind them to reward other accomplishments, even if the reward is a positive self-statement
(Good job! I knew I could do it!). For example, reward small steps such as joining a gym, subscribing to a
fitness magazine, or scheduling appointments with a trainer or a group exercise class.
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• Help your client identify other people and/or groups that they may turn to for help and support. Provide
them with a list of websites that post exercise classes, recreational sports leagues, local road races, and
physical activity meet-up groups.
• Identify the cues in your client’s life that are triggering sedentary behaviors. Can they, for example, leave
some workout equipment (e.g., light weights/ dumbbells, DVDs, or therabands) in places where they
would normally be sedentary (i.e., living room, bedroom, home office, etc.)?
• Encourage your client to substitute negatives with positives. For example, help them:
• Have walking meetings at work.
• Ride a stationary bike while watching TV instead of sitting on the couch.
• Ask a friend to catch up and talk while walking around the neighborhood instead of talking over
coffee.
• Help your client stay up to date on exercise strategies, opportunities, and benefits by encouraging them to
subscribe to fitness-oriented magazines, bookmark their favorite physical activity–oriented Web sites, and
talk to people about specific issues and/or questions about staying on track.
• Encourage your client to monitor their exercise routines, progress, goals, and setbacks. Daily monitoring
is key in identifying where and when setbacks are likely to occur.
The Action section earlier in this chapter provides additional tips on avoiding relapse.
RESOURCES FOR CLIENTS
To provide clients with additional assistance navigating the behavior change process, you can refer them to a
variety of free resources with behavior change tips.
Behavior Change Resources for Clients
Web Sites
Centers for Disease Control: http://www.cdc.gov/physicalactivity/index.html
National Institutes of Health: http://health.nih.gov/topic/ExercisePhysicalFitness; older adults can also find
guidance at http://health.nih.gov/topic/ExerciseforSeniors.
Computer-Tailored Intervention
You can also refer them to an evidence-based computer-tailored intervention for exercise within the
LifeStyle Management Suite of programs available at www.prochange.com/myhealth. Participants can
interact with the fully tailored intervention, which gives individualized feedback on the behavior change
processes they are using and suggestions about what they need to use more or less to move forward. A
demo of the program is available at www.prochange.com/exercisedemo. The suite also contains a
Personal Activity Center that includes interactive activities designed to activate the most appropriate
strategies for change. A nominal fee grants access for 1 year. Participants can print and share their
computer-tailored intervention report with you or other health professionals.
Case Scenario 4.1
leungchopan/Shutterstock.com
Marianne is a 56-year-old woman with hypertension, high cholesterol, and a body mass index of 27.
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She was referred through a worksite wellness program to a session with a health coach, who can see
from her Health Risk Assessment that she is not currently exercising.
During their first call, Marianne reports that she has no intention to begin exercising regularly in the
next 6 months. She explains that she has no time for exercise given her busy work schedule. She also
reports that she does not need to exercise because she is “pretty healthy.” She attributes her weight gain
in the past 5 years to menopause.
What stage of change is Marianne likely in, and what interventions do you suggest?
Intervention Suggestions:
• Raise the Pros
• Decrease defenses—Marianne is blaming her weight gain on menopause, rather than recognizing the
role a sedentary lifestyle could be playing. She is potentially denying the role her sedentary lifestyle
and overweight status is playing in her chronic illnesses, both of which increase her risk of
cardiovascular disease. It will be helpful to point out that we often use defenses, and to assist
Marianne in recognizing hers, so she can use them less.
• Ask Marianne if she has spoken with her health care provider about the role exercise could play in
managing her hypertension and high cholesterol. If she has not, ask her if she will. Would it be
possible to get off the medication she is now taking if she exercised more? Would exercise also lower
her risk of other conditions, such as diabetes?
• Does she pay attention to news stories and headlines about exercise? Could she find one between now
and your next call?
• Does Marianne have children or other young family members (e.g., nieces or nephews)? Is she
concerned about living as long as she can for them or seeing important milestones in their lives (e.g.,
weddings, first babies)? Could exercising help her be there for those special people? Ask her if she has
thought about what type of example she would be setting for them if she were to start exercising
someday.
What else might be an effective intervention for Marianne?
Marianne is in the Precontemplation stage because she is not intending to exercise regularly in the
next 6 months. Another effective intervention strategy for those in Precontem-plation is to encourage
them to look for inspiration from others who have adopted regular exercise. Ask if she knows anyone
who has improved his or her health and well-being by beginning to exercise regularly. How did that
person do it? Does that person’s success inspire her to want to exercise?
Case Scenario 4.2
AlexandreNunes/Shutterstock.com
Bill is a 33-year-old with no notable medical history and a body mass index of 22. He played basketball
in high school and college, but has little time now that he has a new demanding position as a supervisor
at work and a new baby at home. He reports that he is “thinking about” beginning to exercise again
sometime in the next 6 months or so, but has no specific plans. He also reports that he “feels guilty”
spending time exercising after work since his wife seems more overwhelmed when he comes home later.
What stage of change is Bill likely in, and what interventions do you suggest?
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• Stress, a demanding schedule, and feeling guilty over taking time away from his new family are big
cons for Bill. Assist him in overcoming those cons by coming up with practical ways around them
(e.g., Can he exercise on his lunch hour at the company’s fitness facility? Can he ride his bike to and
from work so his transportation is his exercise and he will not be hassled with traffic? Can he find
some way to give his wife a break and exercise by taking the baby for a walk or jog in the stroller?)
and/or comparing them to the advantages he is familiar with (e.g., he will feel less stressed if he
exercises, he is likely to be more productive, and he will live longer for his new baby).
• Can Bill talk to coworkers and friends to figure out how they are fitting exercise into their schedules?
Are there any alternatives that might fit into his schedule (e.g., a gym that opens up early enough for
him to go on his way to work so he can still be home in the evening)?
• Ask Bill to list his values and what is important to him. Is his sedentary lifestyle consistent with those
values? Is that the image he wants his new son to have of him?
• Has he been inspired by anyone who manages to fit exercise in and has benefited as a result? Has he
heard any stories of colleagues who had health problems because they did not take care of themselves
by exercising and eating well?
• Are there any small steps he can take to start to reincorporate exercise into his life?
What else might be an effective intervention for Bill?
Bill is in the Contemplation stage. Another effective intervention strategy for individuals in
Contemplation is to ask him to consider the effect of his inactivity on the important people in his life.
Could he be a better role model to his child, and other people in his life, if he were exercising regularly?
Case Scenario 4.3
Andre Blais/Shutterstock.com
Michelle is a 25-year-old recent college graduate with a body mass index of 25. She is in good health
overall, but would like to drop a few pounds. Her typical workout routine has included 30 minutes a day
on the elliptical machine at the gym in her apartment complex or walking around the neighborhood.
Recently her motivation and adherence to this routine has waned because she is frustrated with her
slowing weight loss. She now reports that she has a hard time consistently exercising because of work
and social obligations. She also seems to be overestimating how many calories are burned during exercise
and the intensity level of her workouts. She reports that she is going to get back on track in the next
week or so, but wants some tips.
What stage of change is Michelle likely in, and what interventions do you suggest?
• Encourage Michelle to renew her commitment to exercising regularly and encourage her to focus on
all of the benefits, rather than just on the potential to lose weight. Ask her if exercise will make her
feel more energetic, confident, and healthy.
• Encourage Michelle to share her commitment to get started again with her friends, family, and
coworkers.
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• Assist Michelle with making detailed plans for how and when she will exercise, anticipating potential
challenges. What will she do when she has to work late or when the weather is bad?
• Help Michelle find accurate information about the intensity of her exercise and educate her about the
duration and intensity needed to burn calories. Does she need to increase the intensity of her exercise
to see the results she wants?
• Encourage Michelle to employ substitutes for negative thoughts that could be getting in her way (e.g.,
If she is busy with work, can she walk or bike there to add more activity to her day or get off public
transportation a few stops earlier? If she feels like she is missing out on social obligations when she is
exercising, can she involve friends in her activity—going for hikes or bike rides? If she is bored with
the elliptical and not getting the results she wants, can she add more variety to her routine?)
What else might be an effective intervention for Michelle?
Michelle is in the Preparation Stage. She had been in Action and is planning to get back on track. To
help Michelle reach her goal, you could suggest that she turn her social network into a support network.
Suggest that she ask for the encouragement of important people in her life and talk with her about how
specifically she can do that. Does she want to challenge her friends informally or formally in apps like
Nike+? If you sense reluctance, ask if a closed social network like LoseIt! might work for her.
TAKE-HOME MESSAGES
Other behavior theories and models are described in Chapter 1. This chapter further details the TTM
as a useful intervention framework for assisting clients in adopting and maintaining regular exercise. It
is crucial to assess each client’s readiness to engage in regular exercise and tailor your interventions to his
or her stage of change. Recognizing the unique needs of individuals in early stages and
reconceptualizing progress as movement to the next stage can significantly increase the impact of
exercise interventions. Adequate preparation prior to taking action has the potential to decrease relapse
rates and assist individuals in recycling more quickly if they do relapse to an earlier stage. The
suggestions and sample activities provided here will assist you in using stage-appropriate strategies for
the entire population of clients with whom you come into contact, rather than the minority who are
prepared to take action.
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One of the biggest challenges facing practitioners is that physical activity (PA) counseling must take
into account both individual motivational variables (e.g., whether an individual wants to exercise or not,
perceived barriers to being physically active) and the sociocultural context in which we live. A natural
tendency for some practitioners is to attempt to motivate a client by showing clients the error of their
ways; using fear messages or exhortation or by prescribing a ready-made exercise plan. However, these
approaches often fail to yield the desired results. Indeed, in much the same way that most people in the
developed world know that smoking tobacco is dangerous for their health, they also already know that
being more physically active is something they “should do” to be healthier. Yet most are not doing
enough of it. Information is not the key driver.
As a practitioner, you are uniquely positioned to energize and motivate your clients to be more
physically active. Providing appropriate motivational support for your clients involves understanding the
reasons they may not enjoy PA. This could include fears, discomfort, or other sources of resistance and
ambivalence as well as the meaning of PA for their health and broader life values. Patient-centered
counseling approaches offer a variety of techniques by which practitioners can support clients’ optimal
motivation, resulting in long-lasting health behavior change. This includes aligning their natural
tendencies toward growth and health with their other life goals and values. Working with clients in this
manner allows them to develop a plan for regular physical activity that is best suited to their specific
needs, values, strengths, barriers, and life stage. Because clients play an active role in addressing barriers,
exploring the meaning of PA, and developing their PA plan, a pattern of regular physical activity will
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more likely be maintained.
In this chapter, we take the perspectives of Motivational Interviewing (MI) (32) and Self-
Determination Theory (SDT) (36,38) to identify client-centered ways in which practitioners can
encourage increased physical activity. We have chosen to take these perspectives in particular for two
primary reasons. First, MI and SDT have demonstrated efficacy in working with those who may be
ambivalent about change, as well as those more ready to change (32,38). Second, an emerging body of
evidence supports the efficacy of these approaches not only for the initiation of behavior change but also
its maintenance. Although MI and SDT emerged in different ways—MI as a counseling style and SDT
as a psychological theory—they are conceptually complementary in many ways (20,51), and both have
been used to develop interventions that motivate long-term change of health behaviors, including
tobacco cessation, reduction of alcohol intake, increases in fruit and vegetable intake, healthy weight
management, and regular physical activity (19,38). More sophisticated discussions of the higher-level
distinctions between MI and SDT have been provided elsewhere (29,50,51). For ease of presentation,
we will discuss MI and SDT as distinct yet complementary approaches useful in a variety of contexts
and settings. Thus, it is not the case that one is necessarily “better” than another in any given situation.
We begin with a brief overview of MI and SDT to clarify their underlying assumptions about human
motivation. Specific strategies used within MI and SDT are then described, along with the training
necessary to successfully implement these techniques in clinical practice. Two specific client-centered
counseling frameworks for physical activity (the 5 A’s and MI’s Explore, Guide, Choose) are presented,
and an overview of the evidence for these approaches is provided. Examples and brief vignettes are
included whenever possible to assist the reader in understanding how to put these techniques into
practice.
A BRIEF OVERVIEW OF MOTIVATIONAL INTERVIEWING AND SELF-

DETERMINATION THEORY
Motivational Interviewing
Motivational Interviewing (MI) is a set of general clinical techniques aimed at addressing clients’ ambivalence
toward change, overcoming resistance to change, and building autonomous motivation. Rather than using
more directive or coercive approaches, MI works from the perspective of the client by aligning behavior
change goals with the client’s broader goals and values. Although it originally emerged out of addiction
treatment, MI has since been used to modify a range of health behaviors relevant to chronic disease
prevention and management, including healthy eating, physical activity, and weight management (19). MI is a
“way of being” that uses strategies described later in this chapter such as reflective listening, shared decision
making, and eliciting change talk.
Effective MI has been described as the strategic balance between “comforting the afflicted” and “afflicting
the comfortable” (30). That is, MI techniques involve balancing the expression of empathy with the need to
build sufficient discrepancy (i.e., between the individual’s current behavior and the behavioral goal and other
personal values) to stimulate change. MI has been shown to be particularly effective with those who are
ambivalent about change (3,15,24,28,31). This may be, in part, because of the nonjudgmental and
encouraging tone that characterizes MI. Practitioners establish a nonconfrontational and supportive climate in
which clients feel comfortable expressing both what they like and what they don’t like about their current
behavior. From the perspective of MI, it is often important to explore ambivalence prior to moving toward
change (30).
Most practitioners learn to offer their professional advice based on their expertise and experience. They may
do so in part to save time, and because they function from a paternalistic “I know what’s best” approach for
motivating their clients. However, an overly prescriptive approach often backfires, creating resistance from
clients more than drive. Using an MI approach, clients do much of the psychological work themselves.
Practitioners, therefore, serve as guides through the process, assisting clients in identifying their own pros and
cons for their current behavior as well as the goal behavior, understanding what prevents them—both
practically and perceptually—from reaching the goal behavior, and developing a plan of action once
ambivalence has been explored and resolved. Within MI, practitioners typically do not directly attempt to
dismantle denial or confront irrational or maladaptive beliefs. Instead, they may subtly help clients detect
contradictions in their thoughts and actions, allowing them to experience discrepancy between their current
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actions and who they ideally want to be. MI practitioners rarely attempt to convince, cajole, or persuade.
Instead, MI encourages clients to make fully informed and deeply contemplated choices, even if the decision
is not to change. The counselor is careful to avoid pushing the client and creating further resistance.
Self-Determination Theory
MI emerged as a set of clinical techniques and thus is inherently practical in the clinical world. By
comparison, Self-Determination Theory (SDT) evolved out of basic social science as a theoretical framework
to understand the bases of human motivation (5,36). Much recent research in SDT has focused on applying
its concepts clinically, including in the area of physical activity (13,39). There is a good deal of conceptual
overlap between SDT and MI, though some differences remain. A sophisticated discussion of the
complementarity and distinctions between MI and SDT is beyond the scope of this chapter. However, several
recent publications have focused explicitly on this issue (20,26,29,47,50,51). Using the principles of SDT,
Williams and others have developed and tested need-supportive therapy for health behavior change for
physical activity, tobacco cessation, weight loss, and medication use (41,54,55). The SDT-based approach
uses many MI-congruent techniques. Additionally, researchers and practitioners alike have begun to use SDT
as the de facto theoretical perspective through which to understand how and why MI techniques work (30).
CONTINUUM OF MOTIVATION
SDT views motivation as having two central components: psychological energy, and the goal that the energy
is directed toward. SDT has articulated a continuum of motivation which ranges from amotivation (i.e.,
lacking psychological energy, or having no reason for engaging in a behavior, or seeking a particular health
goal) to extrinsic motivation (engaging in behaviors for some separable outcome) to intrinsic motivation
(engaging in behaviors for their own enjoyment or interest, and not for any other separable outcome). Figure
5.1 presents the motivation continuum, along with examples of each type of regulation, described in detail in
the following text. Many health behaviors are extrinsically motivated; that is, they are engaged for some
separable outcome (e.g., to eliminate or reduce a symptom, to improve the quality or length of life, to
minimize nagging from a well-intentioned spouse or clinician). Others, like physical activity or healthy
cooking, can also be intrinsically motivating; that is, they can be interesting in their own right and strongly
energized by the enjoyment they provide.
FIGURE 5.1.The motivation continuum.
Within the motivation continuum there are several gradations varying in the degree to which extrinsic
motivations are more or less internalized to the self (i.e., how self-congruent these motivations are, and how
closely they resemble intrinsic motivation) (5,35). The least internalized form of extrinsic motivation, external
regulation, is characterized by engaging in behaviors to gain some reward, such as a financial incentive, or to
avoid some negative consequence, including social sanctions like disapproval or disappointment from others.
Introjected regulation is similar to external regulation in that behaviors are also enacted out of a sense of
pressure or coercion—in this case, pressures that one puts on oneself to behave so as to avoid feelings of shame
and guilt if one failed to perform a behavior as prescribed or up to one’s standards.
Many clients may come into physical activity sessions with these “controlled” forms of motivation. And
although these forms of motivation may be energizing for a time, this is often short-lived and frequently
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associated with poor psychological well-being when compared with more autonomous or internalized types of
motivation. Importantly, although it may seem somewhat intuitive to offer extrinsic rewards to help to get
people started with a regular exercise routine, the preponderance of evidence from basic social science research
broadly, and from SDT in particular, suggests that such tactics are likely to interfere with the process of
internalization (6,36,37). For instance, studies in tobacco cessation (4) and weight control (26) indicate that
changes induced by financial incentives are generally not maintained in the long term. Thus, any short-term
gains that may be achieved by using rewards, social punishments, or attempting to capitalize on the client’s
own propensity for feelings of guilt and shame, are outweighed by the long-term motivational consequences.
Supporting clients to develop more autonomous, internalized forms of motivation is key, as internalized
motivations have been shown to result in greater behavioral persistence (40).
Identified regulation is a relatively more autonomous form of extrinsic motivation. It is characterized by a
belief that the target behavior is personally important and meaningful, and thus the behavior it energizes is
maintained over time. For example, someone may pursue a specific physical activity goal—like training for
and completing a marathon—because the individual believes it is an important goal to achieve. Finally, the
most autonomous (i.e., internalized) form of extrinsic motivation is integrated regulation. With integrated
regulation, the individual believes that the behavior is important and meaningful and is also consistent with
one’s other goals and values. Thus, operating under integrated regulation a person may train for and complete
a marathon because the activity is personally important and is also consistent with the person’s broader goals
and values for being healthy and active.
Importantly, SDT views motivation as dynamic. That is, even though people may have more external
reasons for engaging in a behavior, they may develop more autonomous or internalized reasons over time.
Practitioners are uniquely positioned to facilitate (or impede) this process. Also, it is important to keep in
mind that different types of motivation can and do coexist relative to any behavior, including physical activity.
For instance, some introjected motivation can be present even when someone exercises largely for autonomous
reasons. From an SDT perspective, the important aspect for adherence and well-being is what type of
motivation is predominant.
BASIC PSYCHOLOGICAL NEEDS

The supporting or thwarting of basic psychological needs is the primary mechanism through which
motivation and self-regulation can be changed (6). SDT proposes three basic psychological needs:
competence, relatedness, and autonomy. These needs are consistent with MI principles and techniques (20).
Competence
Competence refers to the need to feel capable of achieving desired outcomes. It is related to the concept of self-
efficacy (i.e., confidence), used in other health behavior theories (1) (also see Chapter 1 and 3). Discussing
psychological and practical barriers to physical activity as well as goal setting and action planning can serve to
meet the client’s need for competence. Identifying the level of physical activity your client is ready for (i.e.,
reaching optimal challenge, not too much or too little) will also support his or her need for competence.
Relatedness
Relatedness refers to the need to feel connected to and understood by important others. Practitioners can
support this need by being empathic, listening to the client’s concerns and asking questions to seek
clarification about what the client is expressing. Relatedness needs may also be supported through being
physically active. For some, this may mean exercising with others or examining how physical activity can
improve their social relationships.
Autonomy
Autonomy is the need to feel volitional, as the originator of one’s actions. By serving as a guide to the client’s
own self-exploration and goal setting, practitioners can support this need and thus promote the development
of more optimal, enduring forms of motivation and self-regulation for their clients. Clients’ needs for
autonomy are also supported by practitioners following the principles of client centeredness; providing choices
or a menu of options for how to go about behavior change and by not pushing their own agenda, particularly
when the client voices ambivalence or reasons against behavior change. For example, when talking with a
client about types of exercise likely to promote health and cardiovascular fitness, some clients may
automatically think of the experience of being told by a coach or gym teacher to run laps (often as
punishment). As a practitioner, you can offer a list of possible activities the client may wish to try out that
would achieve the same health benefits but be more enjoyable (e.g., exercise classes such as Body Pump or
Zumba, dancing, playing pick-up basketball games with friends).
Practitioners can guard against pushing their own agenda by using techniques such as reflective listening, as
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described later in this text. It is important for practitioners not to get attached to a particular outcome or
agenda. Doing so interferes with clients’ capacity to make an informed choice about the direction in which
they want to go with prescribed behavior change, and to have ownership over the plan the client and
practitioner develop together.
MI and SDT Techniques and Strategies

We now provide a general overview of MI and SDT techniques and strategies that can be used when working
with clients around physical activity behavior change. Although we will be discussing a variety of techniques,
it is not necessary to use all of these techniques with every client or in every session. Indeed, the amount of
time one has to interact with the client in a given session, how long you have known the client, and the client’s
attitudes (regarding confidence and importance) toward PA behavior change will all determine which
techniques are most appropriate in a given session. Think of these strategies as a clinical menu from which
you can choose based on your available time and the client’s particular needs. Because MI first began as a set
of clinical techniques, we will use MI terminology but will draw analogies to SDT’s need-supportive therapy
for behavior change as well. Both MI and SDT are client-centered in their approach. Here, we delineate some
specific techniques consistent with the tenets of these perspectives on client-centered counseling.
REFLECTIVE LISTENING
Reflective listening is a hallmark of client-centered counseling. It can be conceptualized as hypothesis testing
or checking in with the client. In practice, this might take the form of, “If I heard you correctly, I think you’re
saying…” or more direct statements such as, “So, you are having trouble with…”. The goal of reflective
listening is to communicate to the client that you have heard and are trying to understand where they are
coming from, affirm or validate their feelings and experiences, and further assist them in the process of self-
discovery. This is, in part, a way to create a nonjudgmental environment from which the client can explore the
positives and negatives of their current behavior and prescribed behavior change. From the perspective of
SDT, which also uses reflective listening, this serves to support the client’s needs for relatedness (i.e., by
conveying an interest in understanding where the client is coming from) and autonomy (i.e., by withholding
judgment about the client). Even if you “guess wrong” about what the client is trying to say, this can be
beneficial as it helps the client to clarify his or her own thoughts, and the practitioner’s openness to correction
can further strengthen rapport.
Reflections range in complexity from the practitioner clarifying that he or she has understood the basic facts
of the client’s story to exploring meaning or feeling behind statements. At least seven types of reflections have
been identified and defined and are described in the following text:
1. Content reflections
2. Feeling/meaning reflections
3. Amplified negative reflections
4. Double-sided reflections
5. Reflections on omission
6. Action reflections (including behavior suggestions, behavior exclusions, and cognitive suggestions)
7. Rolling with resistance
Content Reflections
Content reflections are perhaps the simplest form of reflection and involve reflecting the basic facts about the
client’s story. Although simple, content reflections are important for gathering background information and
building rapport. This might take the form of a statement like, “You tried to exercise regularly before and
were not able to stick with it.”
Feeling/Meaning Reflections
Feeling/meaning reflections often take the form of direct statements about what the client seems to be feeling,
why the person feels a certain way or how something is related to other important aspects of the person’s life.
Building on the content reflection cited earlier, a feeling/meaning reflection may go a step further: “Because
you weren’t able to stick with it before, you are afraid that you will fail again.”
Amplified Negative Reflections
Amplified negative reflections involve exaggerating the negatives of behavior change and/or the positives of
staying the same. Paradoxically, by arguing against change, the practitioner can exhaust the client’s resistance.
“So, for you it makes more sense not to exercise at all than to try to get into a regular routine and fail,” or “You
see no benefit in trying to exercise regularly.” This technique may be particularly useful when clients get into a
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“Yes, but” resistance mindset.
Double-Sided Reflections
Double-sided reflections are particularly important because they convey to the client that the practitioner heard
their reasons for and against behavior change. They also provide an opportunity for the practitioner to
communicate to the client that they accept the client’s ambivalence and are not going to push the client to
change, thus supporting the client’s need for autonomy. An example might be, “On the one hand, you see the
benefits of being more physically active, but on the other hand you are concerned that exercising regularly
would interfere with time you have with your family in the evenings.”
Reflections on Omission
Through a reflection on omission, the practitioner can comment on what the client has not said. For example, if
an otherwise happily married woman states that she has no one to exercise with, the counselor could reflect
back, “So it sounds like your husband is not the answer.” This can further build rapport and expresses to the
client that the practitioner is not going to try to motivate with strategies that the client has already thought
about, tried, and rejected (thus supporting autonomous motivation).
Action Reflections
Action reflections include potential solutions to the client’s barriers or some element of a course of action.
When possible, action reflections provide a menu of effective options from which the client can choose so as
to support the client’s need for autonomy. Because of their focus on actionable items, action reflections may
also serve to support the client’s competence needs. As reflections, these statements involve characterizing
ideas the client has generated or contemplated. Thus, they do not involve giving unsolicited advice. There are
three subtypes of action reflections: behavior suggestion, behavior exclusion, and cognitive suggestion (8).
Behavior Suggestions
Behavior suggestions can take several forms including:
1. Inverting the barrier (e.g., “Starting with shorter, 10-minute bouts and building up to 30 consecutive
minutes of moderate activity may feel less overwhelming and like a more attainable goal for you right
now”)
2. Nonspecific or umbrella strategies (e.g., “So, finding a way to exercise around your house or during the
work day may help.”)
3. Specific strategies based on previous discussions with the client (e.g., “Perhaps mapping out a walking
route around your neighborhood would make it more reasonable for you to exercise regularly.”)
Behavior Exclusions
Behavior exclusions involve reflecting back to the client that, given what they have said, there may be some
options that would not work for them. The reflection on omission technique described previously is one way
in which behavior exclusions can be included in action plans.
Cognitive Suggestions
Finally, cognitive suggestions are another way to express action reflections. These focus more on how a client
may be thinking about physical activity rather than their behavior per se and often resemble the cognitive
component of cognitive-behavioral therapy. (For example, “So, it sounds like when you miss an exercise
session, you feel like you have failed. And when you start thinking that you have failed, you tend to abandon
the effort altogether—which is what really interferes with your goals. Maybe not thinking of exercising
regularly as all-or-none—you’re either meeting the goal or not—would help to make it more doable for you to
be more physically active and reach your exercise goals.”)
Rolling with Resistance
Rolling with resistance is a unique kind of reflection. Confronting clients about their resistance can backfire,
leading to defensiveness, rapport damage, and poor outcomes with respect to behavior change (23). Thus,
instead of arguing with the client, MI suggests that practitioners “roll with resistance.” By rolling with
resistance, practitioners align with clients, essentially agreeing with them even in circumstances where the
client is making factually incorrect statements. An example of a reflection characteristic of rolling with
resistance might be, “You have a very busy life and you work a lot. So, coming home and sitting on the couch
to watch TV is how you unwind at the end of the day.” This approach is the opposite of amplified negative
reflections, described previously.
Rolling with resistance reflections acknowledge the client’s reasons for not changing. They also contribute
to creating a social environment in which the client feels free to express resistance without feeling pressure to
change or worrying about being judged. Rolling with resistance avoids thwarting clients’ autonomy and
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relatedness needs by not forcing them to make changes in any particular way, and by providing an opportunity
for them to explore the change at their pace so they can identify their own reasons for becoming physically
active (autonomy). Rolling with resistance also avoids leaving clients feeling that you are judging them as
weak-willed, or that you don’t like them because they are not doing what you want them to do (i.e.,
unconditional positive regard or relatedness). It further communicates you are not going to push them to
change, but empathize with their struggles.
ELICITING CHANGE TALK

Eliciting change talk is another important component of client-centered counseling. Both MI and SDT start
with the same basic assumption: that humans are naturally oriented toward growth, health, and well-being.
Practically, this means practitioners do not need to tell people to be healthy; clients naturally want to do this,
except in rare circumstance such as clinical depression or complete amotivation. Thus, the practitioner’s role is
to work with clients to identify and voice their personal sources of motivation, since clients are more likely to
accept and act upon goals and plans that they articulate for themselves. The process by which counselors
encourage clients to express their own reasons and plans for change is called eliciting change talk.
Measure Importance and Confidence
Importance and confidence “rulers” are one way to elicit change talk, and this approach has been used in both MI
and SDT interventions. In the context of physical activity, this strategy uses two questions:
1. “On a scale from 0 to 10, with 10 being the highest, how important is it to you to be more physically
active?”
2. “On a scale from 0 to 10, with 10 being the highest (and assuming you want to change this behavior),
how confident are you that you could be more physically active?”
Practitioners then follow up each question with two probes. For example, if the client answered “7,” the
practitioner would first probe with, “You said on a scale of 0 to 10, you would rate the importance of being
more physically active as a 7. Why didn’t you choose a lower number, like a 4 or 5?” This would be followed
by, “What might it take for you to get to a higher number, like an 8 or a 9?” These probes elicit change talk by
providing an opportunity for the client to explore his or her reasons for behavior change as well as where there
may be barriers and potential solutions. Assessing importance is one way to tap into the nature of the client’s
motivations as well as their broader values system.
SDT applications have sometimes modified this question slightly to ask clients how much they want to
engage in behavior change (e.g., being more physically active). Assessing confidence approximates the client’s
perceived competence and can also provide an opportunity to identify potential barriers.
Develop Discrepancy
Another technique for eliciting change talk and energizing motivation is to develop discrepancy between the
client’s current behavior and other life goals and values. Clients may choose from a list of values (e.g., good
spouse/partner, attractive, athletic, on top of things, energetic (30)) or they may generate three to five personal
goals or values on their own. Self-generation of goals or values may be approached in the following way: “Now
I’d like to get to know a little bit more about other aspects of your life and things that are important to you. If
you were to think about the things that are most important to you, or perhaps some things you’d like to
accomplish—either in the short term like the next 5 years or over the course of your life—what would those
things be?”
The practitioner then explores with the client how becoming more physically active or starting a more
regular exercise routine would support or interfere with the pursuit and achievement of those goals. For
example, the client may acknowledge “spending time with family” as something that is important to them.
The client may note that being more physically active may mean spending less time with family, which is less
appealing. The client may also note, however, that by being more physically active they are pursuing a
healthier lifestyle that is likely to contribute to longer length and quality of life, which would provide more
time with family in the long run. Thus, rather than the practitioner telling the client what he or she should do
and why it is important, the client is able to explore this territory on his or her own and align behavior change
with broader life goals and values. The client’s self-exploration supports autonomy needs and also promotes
internalization of motivation for physical activity by bringing physical activity goals in congruity with other
goals and values.
TRAINING: USING MI AND SDT TECHNIQUES SUCCESSFULLY
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There is a considerable literature on MI training techniques, and SDT has used MI training protocols in
teaching SDT practitioners how to utilize SDT and MI techniques in health promotion contexts. Thus, here
we describe training as outlined for MI practitioners, though training for SDT practitioners is quite similar.
Introductory Training
Many practitioners are initially exposed to MI techniques in brief, generally didactic-only sessions like “grand
rounds.” More formal introductory training may begin with studying print materials and training videos. It
may also involve attending an introductory training session lasting up to 1 to 3 days that covers the basic
tenets of MI and the foundation for using MI techniques in practice.
Introductory workshops typically involve a mix of didactic instruction, demonstrations, and hands-on
experience. The purpose of these sessions is to provide training participants with a general understanding of
the spirit and method of MI and to provide practical experience in trying out the approach. Practitioners who
have learned the basics of MI and had the opportunity to use MI techniques in their practice over time may
wish to achieve additional proficiency.
Intermediate/Advanced Training
Intermediate/advanced clinical training often involves having audio or video recordings of sessions of the
practitioner coded by a trainer, who provides feedback about how to further hone MI skills.
Intermediate/advanced training is typically done over the course of a 2- or 3-day workshop and focuses
primarily on demonstrations, opportunities for practice and review of audio- or video-recorded sessions that
training participants have brought in from their clinical practice. Some studies have recently emerged to
evaluate the efficacy of online and other auto-didactic methods for MI training. These approaches show great
promise and are critical for MI to be used on a broad scale. Additional information about MI Manuals and
Training along with train-the-trainer materials can be found at http://www.motivationalinterview.org.
CLIENT-CENTERED APPROACHES FOR ELICITING PHYSICAL ACTIVITY

BEHAVIOR CHANGE
The Traditional Approach: The 5 A’s

Originally developed by the National Cancer Institute as an approach to addressing tobacco cessation in
primary care, the 4 A’s model (ask, advise, assist, arrange) has since been expanded to include a fifth step:
agree, or “assess willingness to change.” The 5 A’s model (ask, advise, agree, assist, arrange), as described by
the U.S. Preventive Services Taskforce, has been used to conceptualize brief interventions across a variety of
behaviors implemented by a variety of health practitioners (e.g., wearing seatbelts, alcohol use, etc.) (12).
Step-by-Step
Ask
Ask involves asking the client about health behaviors and risks and the factors that impact their decision to
change as well as the goals and methods applied to such changes.
Advise
Advise involves giving the client clear, specific behavior change advice, including information about the health
risks of not changing and benefits of implementing change. Within the 5 A’s model, advice has been shown
to be most effective when it is linked directly to the reason for which the person has sought care. For example,
if a client came to a practitioner because they were concerned about their risk for cardiovascular disease, the
practitioner may recommend the kinds of exercise that have been shown to lower cardiovascular risk (e.g.,
moderate and vigorous physical activity).
Agree
Agree or assess willingness to change refers to the collaborative process by which the practitioner and client work
together to determine whether the client wants to change and, if so, identify behavior change goals and
strategies based on the client’s interest and willingness to change the target behavior. By including the fifth
“A” for “agree,” this model directly supports autonomy because it is naturally aligned with engaging the client
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in the development of a plan and exploring and acknowledging client ambivalence.
Assist
Assist is the process by which the practitioner helps the patient to achieve the agreed-upon behavior change
goals by obtaining the needed skills, confidence, and social or environmental supports. Assist directly supports
clients’ needs for competence.
Arrange
Arrange involves the practitioner working with the client to establish a schedule for followup contacts to
provide ongoing support and adjust the treatment plan as needed. Multiple visits and unconditional support
over time can be useful to motivating long-term change such as establishing a healthy pattern of physical
activity. However, there is also the risk that the client perceives these visits (which ultimately will end) as an
external source of reinforcement and motivation (“I have to show my personal trainer/doctor/etc. how well I’m
doing”), which could undermine the development of more internal (and lasting) reasons to sustain new
behaviors.
RELATIONSHIP AMONG MI, SDT, AND THE 5 A’S

It is important to note that although MI, SDT, and the 5 A’s developed independently, because MI and SDT
are primarily about the way in which the practitioner interacts with the client rather than nuts and bolts of
specific clinical behaviors, it is possible to use a 5 A’s, brief-encounter approach in a way that is MI- and
SDT-congruent. For example, one may view MI and SDT as a more comprehensive approach to the first A:
Ask. Additionally, one may use “Agree (willingness to change),” to elicit client autonomy and to explore and
acknowledge client ambivalence, and move forward with “assist” only when the client has expressed a desire to
change.
The one arena in which the 5 A’s, MI, and SDT may be less complementary is Advise. In the context of PA
counseling, advice may come in the form of providing information about current recommendations for levels
and types of physical activity required to achieve certain health goals (e.g., health benefits, reduced
cardiovascular risk, weight loss, etc.). It may also come in the form of providing an exercise prescription or
plan. MI and SDT would suggest that, to support clients’ optimal motivation, it is important to develop an
exercise plan in a collaborative, client-centered way rather than a more paternalistic or prescribing way. As
described earlier, MI recommends against direct advice-giving and maintains that attempts to directly
persuade a client may backfire because such persuasive attempts inherently “take sides” in the ambivalence. In
turn, SDT maintains that one of the keys to supporting patient autonomy—providing structure—is achieved,
in part, by explicitly guiding the client or patient through the various choices they have to best maintain or
improve health and well-being.
For example, to the degree the client feels unsure about the most effective dose or type of exercise to
achieve a certain fitness/health outcome, an explicit recommendation might be offered. However, even in
SDT, advice is not intended to control the client, but rather to provide information about effective options of
treatment. Further, in medical and health contexts in particular, explicit recommendations may be an expected
component of interactions between practitioners and clients. Thus, a practitioners’ refusal to provide such
direction could thwart all three of the patient’s psychological needs and may be experienced by the client as
abandonment. However, SDT cautions that recommendations be given noncoercively, so as to provide
information to the patient while still supporting the patient in making the decision himself or herself (e.g.,
“Research has shown that incorporating regular exercise into your life is important for achieving the weight
loss goals you have identified, but the choice is ultimately yours, and I will be here to support you in whatever
decision you make.”).
Indeed, more recent formulations of MI have allowed for practitioners to make recommendations when
patients specifically ask for advice as discussed later in the three-phase model (Explore, Guide, Choose), and
through action reflections described previously. From the perspectives of both MI and SDT, providing direct
recommendations may occur at any point in the 5 A’s model, depending on the client’s expressed needs and
goals. For example, in the context of Ask, the client may indicate being uncertain about what types of exercise
they need to be engaging in to achieve a weight loss goal. This may be a circumstance in which the
practitioner can provide information about current recommendations or provide options for the client to
consider about the types of exercise he or she would like to engage in. Likewise, in the context of Agree,
during which client and practitioner are working together to establish an exercise plan, the client may ask for
suggestions on how to proceed toward a particular exercise goal. Regardless of when opportunities for direct
advice-giving may present themselves, from the perspective of MI and SDT, it is critical for the practitioner
to check in with the client to ensure that the practitioner is being responsive to the client’s needs and is
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aligned with the client’s goals rather than the practitioner’s own agenda.
Both MI and SDT have used the elicit-provide-elicit framework for providing direct advice (29). That is,
practitioners elicit from the client information about their knowledge and attitudes toward behavior change,
where there may be knowledge gaps, etc., and then provide information and recommendations based on what
the client has indicated or requested. Practitioners then elicit again, asking clients how they interpret the
information that was provided and what the information means to them in the context of their current
behavior. Case Scenario 5.1 provides a vignette that illustrates how the 5 A’s approach might be used in a way
that is consistent with the motivational perspectives highlighted in this chapter. Although we will discuss
these techniques in a linear fashion, it is important to note that not all clients proceed through these phases in
the order specified.
Case Scenario 5.1
Iakov Filimonov/Shutterstock.com
THE 5 A’S IN THE CONTEXT OF MI AND SDT

Your client is a 45-year-old married woman with two children; she is a computer programmer. She was
a college athlete and was physically active during young adulthood but hasn’t been active over the past
10 years. She has gained some weight (current BMI = 28), and she is struggling with negative body
image. She is also worried about becoming obese. She has come to your fitness facility to get a plan for
being more active and losing weight. In the following exchange, P is the Practitioner, and she is C, the
Client.
Ask
P: Hi Mrs. Jones. How are you today?
C: I’m doing okay. I’m ready to start exercising again. I hate my body right now, and I’m worried
about my weight. I used to be active, and I want to get back there.
P: So it sounds like you’ve been thinking about being more physically active. I’d like to learn a little
more about what your daily life is like.
C: Well, my work keeps me in front of a computer all the time, and they always have food around the
office that tastes so good—donuts, muffins, candy. I eat to take a break from my work. And I sit most
of the day.
P: When do you like to exercise?
C: Well, in theory, I could exercise in the morning.

P: But it sounds like maybe that’s not working for you?
C: Not really. Mornings are just so busy with the kids.

P: So, if mornings don’t work for you, what might work–or what might you be willing to try?
C: I think I might be more of an evening exercise person. That’s what I used to do when I was
working out all the time. And since the gym is between work and home, evenings might work.
P: Okay. Let’s see if I have this right. You are unhappy with your current weight and also concerned
about becoming obese. You used to be active, but not recently–mostly because you’ve been busy. It
also sounds like you tried to exercise in the mornings, but that didn’t really fit in with your schedule
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that well. Do I have that right?
C: Exactly. And now that we’re talking about this, I have to admit that, even though I know that
being active is good for me, I really want to lose weight. I’m really unhappy with how I look right
now, and I miss how good I used to feel when I was exercising regularly.
Comment: The summary at the end of this dialogue is important for enhancing motivation because it
lets the client know you have heard her, and makes it more likely she will be able to hear your advice
without feeling controlled. Acknowledging her weight and body image concerns is also key to
understanding central motives around exercise, which may be addressed later.
Advise
P: Now that I have a better sense of where you’re coming from, let’s talk about some
recommendations for physical activity. Is that okay?
C: Yes, I think I have a general idea, but I’d like to know what I need to do–especially to lose weight.
P: It might help to think about exercise less as what you need to do and more as finding a routine that
works for you. You might have heard that you need to get 150 minutes of moderate-intensity physical
activity a week–or 30 minutes of activity on most days. These are activities like: brisk walking, bike
riding, or water aerobics. But it might take more activity to lose weight. How does that seem to you?
C: Wow! 150 minutes seems like a lot. And I have to do more to lose weight? I definitely have my
work cut out for me.
Agree/Assess (willingness to change)

P: 150 minutes sounds like a lot–and the thought of doing more can feel daunting. You might try
thinking about it as something to work toward, with a smaller goal to start–like 10-15 minutes a day.
How does that sound?
C: It definitely feels less overwhelming. But I don’t want to set goals that are so small that I never get
to where I need to be to lose weight.
P: It can be hard to find the balance between “do-able goals” and goals that are not challenging
enough. Let’s talk about some specifics and see how you feel then.
Assist
P: You might start with activities you like to do and build up from there.
C: I really like lifting weights, and I used to run, but at my current weight, it’s really uncomfortable.
Maybe I could use a stationary bike?
P: It sounds like you have some ideas about the kinds of exercise you like. Great! How many times a
week could you get to the gym or exercise from home?
C: I would like to say every day, but I don’t think that’s realistic. Maybe 2 days at the gym?
P: That’s a great start. What days of the week would you like to come?
C: I wasn’t expecting to have to name days. Maybe one time during the week and one time on the
weekend?
P: That sounds reasonable. Can you work out at home at all?

C: My kids love to ride their bikes. Maybe I can go out with them 1 or 2 nights a week.
P: That sounds like a great start! Just to summarize, what I have heard you say is that you are willing
to start with some smaller goals, but ultimately you want to lose weight. For now your plan is:
• Come to the gym 1 weekday and 1 weekend day to lift weights and ride the stationary bike.
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• Go out with your kids to ride bikes 1 or 2 nights a week.
How does that seem to you?
C: I’ll give it a shot.
Arrange
P: I’d like to follow up with you, just to see how things are going and to give you an opportunity to
talk about how this plan is working for you (or where w might need to make some changes). Could we
plan to meet again in 2 weeks?
C: Sure. And maybe I’ll see you when I’m here between now and then?
P: Absolutely. And if you’re having trouble with anything in the mean time and want to touch base,
just send me an email and we can set up a time to talk–on the phone or here at the gym. Or if I’m not
working with another client and we’re both here, you can just come talk to me then.
C: Great. That sounds like a plan that will work for me.
P: Sounds good. Remember, there are lots of ways to become more active. Sometimes it just takes a
few tries before we find the right mix and scheduling that works best for you. And we can talk more
about your weight loss goals–and how to achieve them–when we meet next.
An Alternative Approach: Explore, Guide, Choose

Based on Motivational Interviewing (MI), a three-phase model (Explore, Guide and Choose) delineated by
Resnicow and Rollnick (30) represents another framework for working with clients toward behavior change.
Like the 5 A’s, this approach can be used in brief encounters.
Step-by-Step
As with the 5As model described above, although we will discuss these processes in a linear fashion, it is
important to note that not all clients or clinical encounters proceed through these phases in the order
specified. Indeed, some clients will come into the interaction without much ambivalence, and thus, less time
will need to be devoted to “exploring.” Additionally, quality (i.e., sources) and quantity of motivation are likely
to fluctuate throughout the process of behavior change. As clients experience failures, reemergence of
ambivalence and other motivational slumps, “exploring” and “guiding” may need to be covered again within
the context of these new experiences.
Explore
Similar to the 5 A’s Ask, the primary objective during the explore phase is to obtain a behavioral history,
including prior attempts at behavior change. MI and SDT take this a bit further and view this phase as an
opportunity for the practitioner to “comfort the afflicted,” build rapport, and better understand the client’s
story. Key skills and techniques used in the explore phase include reflective listening, shared decision making
(particularly with respect to agenda-setting), and open-ended questions. Because rapport building is an
important component of this phase, the practitioner conveys empathy and demonstrates for the client that the
practitioner will support autonomy and not push a change agenda. The explore phase includes very little
action planning, although when action ideas come up in conversation, the practitioner may wish to provide a
verbal acknowledgement of plans to revisit them later in the session.
Guide
Once the practitioner has heard and understood the client’s story, and some rapport has been established, the
discussion can proceed to guiding. This phase is characterized by “afflicting the comfortable” as it involves
moving the conversation toward building motivation and therefore the possibility of change. The primary
technique used in this phase is eliciting change talk, including building discrepancy between the client’s
current behavior (e.g., not exercising) and the client’s broader goals and values (e.g., being healthy, spending
time with family) and using the 0-to-10 importance/confidence rulers. The guiding phase concludes with the
practitioner summarizing the discussion, highlighting the client’s potential reasons for making a change, and
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checking in with the client about where that leaves the client with respect to pursuing change. If the client
expresses a commitment to making a change, even a small one, the session can then move to a more practical
discussion of how to implement the said change.
Choose
This is the action phase of the discussion and covers much of the territory covered by the last 4 of the 5 A’s.
Key objectives include helping clients identify a goal, building an action plan, anticipating barriers, and
agreeing on a plan for checking in on progress. Skills and techniques used in the choose phase involve action
reflections and include developing a menu of options for change and setting goals (including mini-goals or
short-term objectives). It is important to keep in mind that, just like other reflections, action reflections are
the practitioner’s “best guess” for what the client has said or where the story is going. Thus, the client may
refute suggestions or get into a “yes-but” mindset. This may result from underlying resistance or ambivalence
that has not been resolved or from previous experiences the client has had with attempted behavior change
and failure.
Even when clients refute suggestions, this provides important information about what does and does not
work and what the client does or does not want to pursue. One technique that may help to minimize outright
rejection and support autonomy is to provide multiple options within a reflection. For example, “Trying to get
in a walk during your lunch hour or inviting the kids to come out with you on your neighborhood walk might
be ways that you can be physically active without losing out on important family time.” Because the provision
of choice supports needs for autonomy, resistance is reduced. Case Scenario 5.2 provides a vignette illustrating
the Explore, Guide, Choose approach.
Case Scenario 5.2
Warren Goldswain/Shutterstock.com
EXPLORE, GUIDE, CHOOSE

Your client is a 58-year-old married man who is a long-haul truck driver. He recently had a heart attack,
and becoming more physically active is part of his cardiac rehabilitation. Although he was active in
sports throughout high school, he has not been physically active much at all as an adult. His recent heart
attack seems to have gotten his attention, though. In the following exchange, P is the Practitioner, and
he is C, the Client.
Explore
P: I understand that your doctor has recommended that you become more physically active. How are
you feeling about being more active in your daily life?
C: Well, my heart attack sure got my attention. And I’ve known for a while that I should be more
active than I am. I sit a lot with my job. I used to really like sports when I was a kid, but that seems
like forever ago.
P: So it sounds like you were jolted by your heart attack. You’re concerned about how much time you
spend sitting at work. You’re also a little unsure about what it will be like to be more active at this
point in your life—that maybe you won’t be the star athlete you once were.
C: Yeah, I huff and puff just walking up stairs so I can’t imagine doing… what did my doctor call it?
Moderate to vigorous activity? For 30 minutes a day?!
P: Exercise may not seem like much fun, and getting to 30 minutes must seem daunting.
C: Yeah, but I know I need to do it. I don’t want to have another heart attack or, worse, have to have
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bypass surgery.
Guide
P: So on a scale from 0 to 10, with 10 being the highest, how important is it to you to be more
physically active?
C: Oh, it’s real important. I’d say probably a 6 or 7.
P: So you would rate the importance of being more physically active as a 7. Why didn’t you choose a
lower number, like a 4 or 5?
C: Well, like I said, I definitely don’t want to have another heart attack. And I know it’s good for my
health to exercise more.
P: And what might it take for you to get to a higher number, like an 8 or a 9?
C: Oh, I don’t know. I mean, I think it’s important to be active. I just don’t know how realistic it is for
me to fit it into my daily life. I’m out on the road a lot. So it’s not like I can go to the gym whenever I
want. And my job’s not going to change, so I’m still going to be sitting all that time.
P: On the one hand, you see the benefits of being more physically active, but on the other hand you
feel like the sedentary nature of your job might cancel out those benefits.
C: Yeah, and I just don’t know how I’m going to do it. But I want to be healthy and active with my
kids and to see them grow up.
P: This feels like a big change to undertake, but there are important parts of your life—like being
healthy and being able to see your kids grow up—that would benefit from you taking better care of
yourself by being more physically active.
Choose
P: From what you’ve said so far, there are two barriers that you see to being physically active on a
regular basis: (1) you are concerned about fitting physical activity into your busy work life, and (2)
because your job will still require you to sit just as much you feel like maybe this undermines the
benefits you might get from exercising regularly.
C: Well, I think it’s important for me to know whether my effort is worth it. If I’m sitting like 10
hours a day, does it really matter if I get in that moderate to vigorous activity for only 30 minutes?
P: So you are wondering if exercise still pays even if you are sitting a lot the rest of the day. I would
like to share with you what we know about that. It does, actually. We know from research that being
active at a moderate level of intensity—so your heart rate is elevated a bit but you’re not completely
winded—for 30 minutes a day goes a long way toward improving your health. Of course, if you could
be active for more than that, that’s good too. What do you make of that?
C: OK. But I still don’t know how I’m going to do it. I can’t get to the gym.
P: You are looking for a way, other than going to the gym, to be active in a way that fits with your job.
C: I guess I could take little walk breaks when I stop to fill up the truck.
P: So what might that look like?
C: I don’t know. Probably only 10 minutes or so. Not the full 30. Does that even count?
P: Absolutely. How might you make these walk breaks happen?
C: I could bring my sneakers and comfortable clothes with me…
P: So you can commit to getting in at least three 10-minute walk breaks each day when you’re stopped
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to fill up your truck. Let’s touch base again in about a month to see how that plan is working for you.
You might find that this works out just fine, or that maybe we need to make some adjustments. Either
way, let’s plan to talk about what’s working for you and what’s not so that you can get closer to
achieving your physical activity and health goals.
THE EVIDENCE FOR CLIENT-CENTERED APPROACHES
There is a solid evidence base for both MI and SDT in health behavior change settings. Early studies of MI
and SDT focused on substance abuse and tobacco cessation, as well as engagement in sports and physical
education (18,42,49). Here we limit our overview to the evidence for MI and SDT in leisure-time physical
activity. In addition, there is considerable support for the 5 A’s model, particularly for use as a brief treatment
(3–10 minutes, for two to four visits) for tobacco and alcohol abuse and dependence, though a more detailed
description of this evidence base is beyond the scope of this chapter (10,53).
Motivational Interviewing and Physical Activity

Several systematic reviews and meta-analyses of MI applied to behaviors relevant to chronic disease
prevention and management have been published in recent years. In a review of brief MI interventions by
Dunn and colleagues, MI was found to be more effective for facilitating exercise (and diet) change than
change in other health behaviors (8). In a meta-analysis of 30 randomized controlled clinical trials examining
the effectiveness of adaptations of MI (e.g., MI interventions that also include non-MI components such as
norm-based feedback), Burke, Arkowitz, and Dunn (2) reported that adaptations of MI were as effective as
other active treatments and more effective than no treatment and placebo controls for improvements in
exercise adoption and maintenance (follow-ups ranged from 4 weeks to 1 year), as well as several other health
behaviors. In their meta-analysis of 72 randomized, controlled trials involving diet, exercise, diabetes, and
substance abuse, Rubak, Sandbaek, Lauritzen, and Christensen (34) found that, overall, MI outperformed
traditional advice-giving in 75% of the studies reviewed. Resnicow, Davis, and Rollnick (27) reviewed youth
studies that used MI to modify diet or physical activity, diabetes, and other behaviors such as smoking and
found some evidence for the feasibility and utility of MI with children and adolescents. Their review also
included some adult studies that used MI to promote change in diet or physical activity (27). Van Dorsten
(48) reported that MI substantially improved diet and exercise behaviors, treatment adherence, and weight
loss in 10 studies targeting weight loss and/or exercise.
In another review, 24 published empirical studies were identified that used MI as an intervention for diet
and/or exercise behaviors (21). Across these studies, MI was shown to be effective for diet and exercise
behavior change both alone and in combination with other interventions. With regard to exercise, clients
receiving an MI intervention reported greater exercise self-efficacy and increased physical activity behavior.
MI has also been shown to facilitate healthier eating (i.e., reduced caloric intake, increased fruit and vegetable
consumption) and improve weight loss outcomes (e.g., decreased BMI) (21). Finally, Lundahl and colleagues
(19) published a meta-analysis on 119 studies with outcomes including substance use, gambling, engagement
in treatment, and—more germane to the present discussion—health-related behaviors such as diet and
exercise. Across studies, MI produced statistically significant, though small (average g = 0.28) effects
compared to weak comparison groups. When judged against specific treatments, MI yielded statistically
nonsignificant results. Further analyses suggested that feedback (e.g., via motivational enhancement therapy),
delivery time, manualization, and delivery mode (group vs. individual) moderated outcomes. It is worth noting
that previous reviews and meta-analyses, as described earlier, found that MI was more effective for physical
activity and exercise than for substance use treatments. The Lundahl and colleagues (19) meta-analysis did not
present results differentiated by behavioral outcome. Taken together, these reviews and the studies that
comprise them provide strong evidence for the clinical utility of MI for physical activity behavior change and
that additional research is needed to better elucidate the clinical utility of MI for pediatric physical activity
promotion and obesity prevention.
Self-Determination Theory and Physical Activity

As a general theory of human motivation SDT has addressed both the characteristics of motivation toward
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prescribed behavior (i.e., the extent to which motivations are more or less internal to the self) and the
importance of psychological need support (i.e., for one’s inherent needs for autonomy, competence, and
relatedness) from the social context in facilitating the emergence of more internal forms of motivation. Several
studies applying SDT to physical activity demonstrated associations between internalized or autonomous
forms of motivation (i.e., intrinsic, integrated, identified) and greater exercise behavioral engagement,
adherence to exercise recommendations over time, perceived competence, and psychological well-being. These
were primarily observational studies (7,17). Additional evidence has demonstrated that the
socioenvironmental context provided by the support of psychological needs for autonomy, competence, and
relatedness facilitates internalization of motivation which is, in turn, related to exercise behavior (9,14).
Recently, investigators have begun testing SDT-based interventions for physical activity. For example,
studies that experimentally prime more autonomous motivations, through the use of need-supportive
techniques (described earlier), evidenced increased exercise intentions and behaviors (9,14). Interventions
implemented in applied settings such as primary care and personal training have also been developed and are
being tested (9,11,25). Given the role of physical activity behavior in various health outcomes, SDT-based
interventions targeting cardiovascular health, diabetes, and overweight/obesity have also used SDT techniques
to promote physical activity. Very recently, a systematic review of 66 empirical studies of SDT and
exercise/PA (observational and experimental) found that autonomous forms of motivation, both extrinsic and
intrinsic, consistently predicted increased PA participation, in some cases in the long term (46). In this review,
higher levels of internal goals for exercising (e.g., affiliation and social engagement, challenge, and skill
development) were also clearly associated with exercise participation. Reviewers concluded that reporting high
perceived competence for exercise positively predicts more adaptive exercise behavioral outcomes.
For example, in a study of patients in a community-based primary care practice, sedentary patients who
worked with a SDT-trained physical activity counselor, compared to those who worked with a physical
activity counselor using usual care practices, experienced greater need support in the health care climate. This
predicted greater increases in autonomous self-regulation for physical activity and, in turn, increases in
perceived competence for physical activity. Both autonomous self-regulation and perceived competence for
physical activity predicted greater increases in physical activity behavior (i.e., number of days in the past 6
weeks in which the participant engaged in light, moderate, or intense leisure-time activity for 20 minutes or
more) (11).
In a one-year, SDT-based intensive behavioral intervention for weight loss among overweight and obese
women, moderate and vigorous PA was significantly higher for women in the intervention compared to the
control at the end of the intervention and at 1 and 2 years post-intervention (40,41). The intervention
explicitly targeted increasing intrinsic motivation—namely enjoyment of physical activity—and autonomous
regulation more generally. The effect of the intervention on autonomous regulation was notable because it was
large, it was sustained over 2 years, and it mediated the effect of the intervention on physical activity 1 year
after the intervention was over (40). Further evidence from this study has suggested a “motivational spill-over”
whereby autonomous self-regulation for exercise predicted autonomous self-regulation for healthy eating over
1 year (22). Thus, facilitating autonomous self-regulation in one health domain may increase autonomous
self-regulation in other, related domains. In sum, the studies summarized here represent a strong evidence
base for using the tenets of SDT to promote physical activity behavior change.
Tailoring and Cultural Considerations

Although many patients report great satisfaction and improved outcomes from patient-centered approaches
(33,44,52) such as MI or SDT, some individuals indicate that they prefer a more directive, educational style
(45). In one recent study (43), where rural African American women viewed an MI training video showing
both MI- and non-MI-consistent practices, many expressed concern that the MI consultation was too
patient-centered. One participant commented, “He [provider] was asking the patient more about his decision,
instead of him [provider] telling him.” Another patient stated, “He [health care provider] [was] not giving the
patient much information. He’s supposed to know; he’s a doctor.” Many patients implied that a more
practitioner-centered, directive approach, where the health care provider did most of the talking and offered
unsolicited advice, was desired. As described earlier, SDT supports providing that advice when the client asks
for it. Practitioners, therefore, need to tailor their intervention style to clients’ preferences and cultural
background.
Several issues are worth keeping in mind when working with diverse populations that may have different
expectations about encounters with health professionals. MI and SDT, as client-centered approaches, are
oriented toward tailoring the clinical approach based on the client’s expressed preferences, concerns, and goals.
Thus, it is possible to be clinically consistent with the tenants and techniques of MI and SDT while providing
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varying degrees of structure, advice, and so forth. Further, from the perspective of SDT, autonomy is not
synonymous with independence. Rather, functioning in an autonomous way involves perceiving that one is
the originator of one’s actions, which may involve varying degrees of input from others.
This has been a critical issue of study in the area of cross-cultural research on basic psychological needs.
Evidence has consistently demonstrated the universality of the need to be autonomous (5). However, the
circumstances under which people experience autonomy may differ. For example, in more collectivist cultures,
it is not uncommon for people to consult with family, friends, or other community leaders prior to making
important decisions—including decisions about health and health behavior. They may seek input from others
and experience this input in more or less autonomous ways. That is, they may volitionally choose to seek input
from valued others or they may feel pressured or coerced to do so. Thus, it is not the seeking of input or direct
advice-giving per se that is more or less autonomy supportive. Rather, it is the way in which the seeking of
advice is approached and the way in which advice is delivered that is key.
TAKE-HOME MESSAGE
Working with clients who are ambivalent or amotivated about health behavior change can be
challenging. Indeed, there is much in modern society that makes physical inactivity the default, and
getting people to move from that default (psychologically and behaviorally) poses unique opportunities
for practitioners. This chapter has provided some options for working with clients to promote physical
activity, even in these difficult circumstances. First, consistent with MI and SDT, practitioners may
wish to begin with the assumption that humans are naturally oriented toward growth, health, and well-
being, while simultaneously acknowledging that many clients may be ambivalent about behavior
change. By starting with these assumptions, practitioners are better equipped to show empathy for the
challenges clients face and to attempt to understand where clients are coming from. Starting from the
position that clients are able to enact change and providing empathy with their struggles enables
practitioners to work with—rather than against—clients in their ambivalence and resistance to change
by supporting their psychological needs. Thus, practitioners can help “plant the seeds” of lasting
motivation and guide clients toward healthy levels of physical activity.
From the perspective of both SDT and MI, health professionals working in the exercise/ PA arena
would do well to not be excessively focused on producing immediate behavior change in their clients or
patients, even if they themselves feel some internal or external pressure to produce results. Instead
practitioners are encouraged to:
1. Explicitly focus on long-term behavioral outcomes (months, years) and share with clients the
importance and value of lasting change (and what it may take to reach it);
2. Do their utmost to create the best counseling and experiential environment for clients’ internal
motivation to arise (when and if it does) instead of feeling that it is the role of the counselor to
“motivate” the client;
3. Be confident in the client’s natural desire to be healthy and vital, trusting that it is he or she, when
and if adequately motivated, who will ultimately find the best solution to overcome what stands
between him/her and a more physically active lifestyle.
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ELECTRONIC TECHNOLOGIES AS COMMUNICATION CHANNELS FOR
PHYSICAL ACTIVITY MESSAGE DELIVERY
In this age of electronic media and wireless communication, there are multiple ways to deliver a physical
activity program. The Internet, computers, and mobile phones can be harnessed to customize and
automate physical activity intervention programs that can provide instruction, motivational messages,
goal setting, and feedback in ways never before possible. In addition, there are new types of devices to
use with these technologies for collecting information from individuals about their activity patterns.
Devices such as pedometers, heart rate monitors, and GPS units—as well as technologies that have
accelerometers, gyroscopes, and temperature sensors built into them—can provide monitoring and
feedback to individuals, coaches, or health care providers about activity levels and other health
indicators. This chapter sorts through and explains the barrage of electronic technologies and how they
have been implemented and evaluated as channels for delivering physical activity programs. Before we
delve into each type of technology and present step-by-step recommendations for their use, we will
provide some background on ways of thinking about communication systems.
A COMMUNICATION MODEL APPLIED TO DELIVERING PHYSICAL

ACTIVITY INTERVENTIONS
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Berlo’s (10) S-M-C-R model of communication defines communication as a process that works through a
Source that delivers the Message through a Channel to a Receiver. When we apply the S-M-C-R model to
deliver physical activity interventions, the Source is you and your intervention system, which includes the
decision rules that determine the appropriate Message to send. The Message is the content of the intervention
and is delivered through different Channels, such as printed materials, Web sites, text messages, or Twitter
“tweets” that are Received by users interested in changing or maintaining their physical activity level. Velicer
and colleagues (111) added the Feedback channel to the S-M-C-R model to explain how a behavior change
intervention determines the specific elements on which to tailor the intervention for the Receiver. This
information could come from survey responses to questions about motivation and barriers to being physically
active and from sensor data collected from a pedometer, accelerometer, or other data capture device to
determine levels and patterns of physical activity.
For the technologies presented in this chapter that serve as the Source—Message channels and Feedback
channels (S-M-C-R-F)—we emphasize designing interventions to influence physical activity through human
computer interaction (HCI) rather than computer mediated communication (CMC) (36). In HCI, the
Receiver interacts with computerized message channels such as mobile phone texting or a Web site that
delivers content determined by computer algorithms and Feedback channels such as a sensor device that
captures physical activity levels. CMC, on the other hand, facilitates person-to-person communication
through technologies such as instant messaging, Skype, or WebEx. The distinction between HCI and CMC
is subtle but important. One important difference is that CMC allows for one-to-one communication and
does not “scale up” to allow you to reach a large number of individuals in a timely and cost-effective manner.
The automatic approach of HCI is designed to mimic the experience that occurs through CMC and face-to-
face interactions.
HCI opens the range of possibilities for how physical activity interventions can be delivered. One-to-one,
face-to-face interaction was the typical way people received a physical activity intervention through a trainer
or health care provider. Similarly, one-to-many interactions to deliver an intervention were typically delivered
through group sessions or classes. Now, HCI can simulate many of the aspects of one-to-one interactions but
deliver “customized” programs to many people through interactive Web sites, mobile applications, and
computer-tailored print materials. Thus, HCI allows scaling of one-to-one interactions so they can be
delivered as one-to-many interactions. In addition, social media technologies such as Facebook allow for
many-to-many delivery for physical activity promotion. Many-to-many delivery can happen, for example,
when you post a physical activity tip on your Facebook page and many people see your post and repost your
tip on their pages, linking you to people who you did not contact directly. This chapter presents multiple
examples of types of HCI actions possible with different communication technologies.
Continuing with how the S-M-C-R-F model applies to technologies for delivering physical activity
interventions, there are important aspects about the Receiver to consider. Ideally, you want to develop and
direct your intervention program to those in different phases of physical activity “readiness” (97). For example,
knowing a person is new to physical activity and is in the Adopter phase would lead you to develop a program
different from one designed for someone who is already active and needs motivation to stay a Maintainer.
Similarly, someone who was previously active but currently is not—for example, because of injury or
pregnancy—would likely get a different kind of intervention geared toward the Relapse phase. Many other
aspects of the Receiver may be important to determine, which can help customize the intervention Message,
such as age, gender, and physical activity goals. The latter might be a key part of your intervention program,
and you will need to determine whether someone is interested in intentional leisure types of physical activity
(e.g., running, swimming, team sports) or increasing activity through incidental-utilitarian types of activity
such as taking the stairs instead of the elevator or walking to destinations instead of driving.
This brings us to the type of Message content you will need to develop that will be delivered in your physical
activity intervention. Kreuter (61) conceptualized a spectrum of communication content types, from a
completely generic content to a completely individualized tailored content. With generic content, there is the
assumption that “one size fits all” and intervention content does not need to be altered based on characteristics
of the individual. “Tailored” intervention content is designed for one particular individual based on his or her
specific characteristics (e.g., motivation level for physical activity, perceived barriers to being active). In
between generic and tailored communication is content “targeted” to a subgroup of people, usually based on
one or more demographic characteristics (e.g., age and sex). The type of Message content you use in your
intervention may be determined by factors such as the nature and size of the target population, the budget,
and HCI technologies that will be used in the Message and Feedback channels of your intervention. In this
chapter, we will mainly focus on developing tailored interventions and how different technologies facilitate
delivering tailored message content.
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The sections of this chapter focus on the communication Channels, both for content and for feedback to the
Source. We begin with computer-generated print materials, and then turn to electronic media such as Internet,
video, and interactive voice recognition (IVR). Next, we present two newer technologies for intervention
delivery: Short Message Service (SMS) text messaging and social networking platforms. From there, we
switch to the feedback devices such as pedometers, accelerometers, heart rate monitors, and GPS units. The
chapter concludes with ways that Message and Feedback channels can be integrated into smart mobile
applications and other technology platforms. This chapter is geared to those interested in creating their own
physical activity intervention program either through developing a “custom” system or by using “off the shelf”
commercial products.
COMPUTER-GENERATED PRINT MEDIA
The “gold standard” for delivering physical activity programs is face-to-face contact with a health professional
or a certified personal trainer (79). However, the time and cost of these programs often makes them
inaccessible to many people. There is a long history of physical activity instructions and self-help materials
delivered through books, pamphlets, and newsletters. Print materials can be used to provide a structured self-
help program or to supplement face-to-face training sessions. Print materials can be handed out at the point
of service, such as athletic clubs, gyms, health care clinics, and work-sites, or they can be mailed directly to
patients, employees, club members, and clients. Electronic print materials can also be e-mailed to individuals
or made accessible on Web sites. Providing print materials is a way for health professionals to deliver
information to their patients that they do not have time to cover during a clinic visit or as a means to reinforce
messages they give at a counseling session. The printed materials serve as a reminder to the individual and
information that the client can refer to between clinic visits or sessions.
Since the early 2000s, considerable information about physical activity has become available on the Internet,
and 8 in 10 U.S. Internet users have searched for health information on the Web (http://pewinternet.org).
Thus, Internet sources have a wide reach for interested consumers, yet the quality of information and
appropriateness to the individual may vary considerably. Electronic print materials can consist of existing
generic print materials simply provided directly on the Web. Organizations such as the American Heart
Association, American College of Sports Medicine, the American Academy of Family Physicians, and American
Council on Exercise (ACE) have online materials available. However, a major advantage of electronic print
media is the potential to customize materials either for groups or to individuals. Customizing information to a
group is often called “market segmentation” or “targeting.” For example, developing a monthly physical
activity newsletter just for seniors would provide specific information about types of physical activity that
would appeal to this population age segment.
On the other hand, tailored materials are designed to mimic the strengths of individual counseling such as
interpersonal contact, interactivity, and immediacy of feedback. Tailored information can range from
superficially “personalized” materials that use a person’s name to generate interest but deliver generic
information, to highly individualized tailoring that provides feedback based on assessed knowledge, attitudes,
and behavior history.
Tailored electronic print materials require information to be collected to tailor the messages and feedback.
Information can be collected by mail, at a kiosk, or online. How data are collected and the information is
delivered determine the immediacy of the information. There will be a significant delay if a person must mail
a survey and the survey information has to be entered into a computer system to generate a tailored feedback
report. In comparison, a computer kiosk or online assessment can be completed and immediately tailored for
the individual, and delivered to them.
Evidence
Multiple reviews of tailored health behavior studies generally have concluded that tailoring “works” (84). For
example, when reviewing eight studies that specifically compared tailored to nontailored print materials,
Skinner and colleagues (102) found tailored information enhances the impact of the printed intervention
materials (in terms of being better remembered, read, and perceived as relevant) compared to nontailored
materials. Skinner et al. also found tailored print materials to be more effective than nontailored for changing
health behaviors (e.g., diet, physical activity, smoking, mammography screening). However, only one of the
eight studies focused on physical activity. Similarly, from a review of 30 studies on physical activity and diet
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behavior change, Kroeze (63) concluded that the evidence in support of computer-tailored interventions for
diet was strong. However, from the 10 physical activity–tailored intervention studies, the evidence was not
sufficient to conclude in favor of computer-tailored interventions.
Several studies have demonstrated that tailored print material interventions work for promoting physical
activity. For example, Marcus and colleagues (72) demonstrated that stage-targeted materials outperformed
standard American Heart Association generic print materials. Marcus (73) compared tailored print materials to
tailored Internet delivery, and to standard Internet delivery, which consisted of links to six publicly available
physical activity Web sites. The tailored print and Internet groups received the same information and groups
were instructed to complete physical activity logs. Participants in all three groups (N = 249) increased activity
from being sedentary to between 80 to 90 minutes of physical activity a week over 12 months. The findings
suggest that all three types of programs were effective likely because they included prompted self-monitoring
with physical activity logs, which is known as an important behavior change strategy.
A similarly designed study randomized sedentary adults to print and telephone-delivered tailored
interventions, or to a control group condition (74). A total of 14 contacts were made over 12 months with
materials either mailed or delivered by telephone health counselors in the print and telephone groups,
respectively. Although both intervention programs increased physical activity by an additional 40
minutes/week compared to the control condition at 6 months, by 12 months only the print materials
condition was significantly more active than the telephone and control groups. These findings suggest that
both intervention modes may be effective for helping people in the adoption of physical activity, but the print
materials may be more effective than telephone counseling for maintaining physical activity. It may be that
having the printed tailored intervention materials available to review at any time is helpful in keeping a person
motivated to be physically active.
Some studies have examined the effect of tailored print materials targeting both physical activity and diet
behaviors. Van Keulen (55) randomized individuals to receive either four computer-tailored letters, four
motivational interview telephone calls, a combined intervention (two letters and two calls), or a control group.
Interventions were delivered within 12 months and all three interventions improved physical activity and diet
compared to the control group. Another study randomized breast and prostate cancer survivors to receive a
10-month program of either tailored or nontailored mailed print materials for improving physical activity and
diet behaviors (29). Although cancer survivors in both programs improved health behaviors, the tailored
program was found to be more effective.
Unfortunately, there is no definitive evidence on how much printed materials need to be tailored to be
effective, or exactly what factors need to be tailored. For example, demographic characteristics, level of
motivation, perceived barriers, and use of behavior change constructs are just some of the factors that could be
the basis for tailoring intervention materials. It is also not known how often tailored interventions need to be
delivered. For example, counter to intuition, a single mailing of print materials was more effective at
promoting physical activity than multiple mailings (75).
Step-by-Step
Kreuter (61) outlined a five-step process for developing tailored intervention materials. The steps presented in
Table 6.1 incorporate Kreuter’s steps, with additional decisions that need to be made when developing a
print-based tailored intervention program.
TABLE 6.1 Steps in the Process of Developing a Print-Based Tailored Intervention
Step Key Questions and Tasks
1. Preliminary What is the purpose of program? Is it to supplement or enhance a “face-to-face” program, or will this be a “stand-
Steps alone” self-help program?
Who is your target audience? Will the program target multiple phases of physical activity, such as adoption,
maintenance, and relapse?
In what setting will the printed materials be distributed? Possibilities include an individual’s home, gym, worksite, or
health care clinic. The setting may influence the look, content and “branding” of the print materials.
2. Intervention Will the structure of the intervention be a newsletter, a report, or a pamphlet? Will the content be based on a
Content scientific theory and evidence? Theories and models of persuasion and behavior change can be drawn from fields of
communication, psychology, and sociology (Neuhauser 2003). On which determinants of physical activity do you
want to focus? How extensively will the content be tailored?
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3. Partnering with The decisions in steps 1 and 2 will lead you to determine who to partner with to develop the printed materials. Do
Experts you need a graphic designer, computer programmers, a printing company, copyeditor, or health care professionals?
4. Gathering and How will the determinants of physical activity be measured? Do validated survey measures exist? How will collected
Storing information be stored in a database?
Information
5. Creating the Create tailored messages that vary by levels of the measured determinants. Develop algorithms and a computer
Intervention program for determining how survey responses about determinants are linked to specific tailored messages. The
System algorithms are rules or decisions that the computer follows to “act” like the human expert (e.g., coach, counselor,
health care provider).
6. Other Consider what the appropriate reading level should be for your printed materials. It is recommended that health
Considerations literature be written at a 6th-grade reading level so it is accessible to lower literacy individuals.
What is the time frame for the delivery of the intervention materials? For example, will it be weekly, monthly, or
semiannually? The time frame is an important consideration and relates to the overall structure of the printed
materials and how much content will need to be developed.
Case Scenario 6.1
Sam72/Shutterstock.com
You are hired by a large business to assist with a yearlong “Workplace Wellness” initiative for their
employees. Your job is to create print materials to help employees increase their physical activity levels.
Worksite: Customer service center

Number of employees: 500
Age range: 18–60
Gender: 65% women
Education: 25% high school graduate, 65% college degree, 10% graduate degree
Main physical activity barrier: Most of the employees sit at a computer for 8 hours a day, 5 days a week.
Because you will not be providing any other counseling to these individuals, the materials must stand-
alone and be self-explanatory. The materials need to target multiple phases of physical activity (i.e.,
adoption, maintenance, and relapse) as this is a yearlong program and the employees will likely start at
different physical activity levels. You determine that the best way to deliver these materials is via e-mail,
as this method is efficient and inexpensive. In addition, the employees may be more likely to read the
materials if the e-mail comes from a reliable source like the Human Resources or Health Services
department. The materials will be in a newsletter that employees can easily print out or that can be read
on the computer. The content will be based on Social Cognitive Theory. Because the employees are
sedentary for most of the week, the focus of the materials will be on environmental determinants of
physical activity such as access and time barriers. About 40% of the content will be generic, but given
the demographics of the company, you decide it is best to tailor the remaining 60% of the content on
age, gender, and the current phase of physical activity. You hire a behavioral health consultant to help
base the content on evidence-based behavior change theories and a computer software engineer to help
you create computer algorithms for tailoring the content. You also plan to hire a copyeditor and a
graphic designer so the product has a professional look and is attention grabbing. The determinants of
physical activity will be measured quarterly with a validated, electronic questionnaire distributed to the
employees via e-mail. Information will be collected on a secure database. Finally, the computer
algorithms will link the information collected from these questionnaires to specific tailored messages to
create the tailored print materials.
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ELECTRONIC MEDIA: INTERNET AND INTERACTIVE VOICE RESPONSE
Electronic media such as Internet-based and automated telephone systems have the potential for reaching
many individuals at a low cost. For example, the Internet has global reach, with widespread adoption in the
U.S. (e.g., 79% of adults use the Internet: pewin-ternet.org, August 23, 2011) and about 30.2% (approximately
2.1 billion people) of the global population, with rapid growth observed in developing areas such as Africa
(2527% growth since 2000) and the Middle East (1987% growth since 2000: Internet World Stats, 2011).
There are many advantages of computer/Web-based interventions for health behavior change, such as ease of
dissemination, access, anonymity, interactivity, and graphical interfaces. Further, after initial setup costs,
maintenance of these Web sites is relatively low-cost (8). Interactive voice response (IVR) systems are
computer-directed interactions via the telephone (e.g., when you call a company, your initial interactions are
often with a computer- automated voice, which is an IVR system). These technologies have gained popularity,
not only for call service centers but also for health promotion because they can be automated to provide a
variety of health services ranging from automated appointment reminders to data gathering and physical
activity coaching.
Evidence for Internet Interventions
Several scientific reviews have explored the value of Internet-based interventions (16,28,82, 114). In general,
most reviews have suggested insufficient evidence for Internet-based interventions as an effective strategy for
physical activity interventions. Despite this, a more meta-analysis exploring the efficacy of Internet-based
interventions as social marketing for behavior change more generally, not just for physical activity promotion,
showed “small but statistically significant effects” across 30 studies (28). Almost all of these previous reviews
highlight the early nature of Internet-based programs, along with the need for additional research.
When interventions did show evidence of working, it tended to be when they were compared to no-
treatment control groups (12,49,50,78,103). There was less supportive evidence of Internet-based
interventions relative to other active forms of intervention, such as tailored print-based media (73). A study
comparing two Web sites showed that a neighborhood-focused Web site that was updated often resulted in
significantly improved physical activity participation over a 26-week period relative to a nontailored
motivationally focused Web site (34).
Short-term intervention programs seem to be more effective than longer-term programs (28). A major
problem of most Internet-based interventions is that people stop using the program regularly with many
showing low return visit rates to the Web sites (32). Internet-based interventions had attrition rates greater
than 20%, suggesting the continued need to explore methods for improving adherence.
When designing a Web-based intervention, there are two major types of design features to consider: those
features that improve the return/retention rate of the use of the Web site and those features that promote
physical activity. Each of these types of features will be discussed in turn based on previous literature and
specific recommendations will be given.
Previous research has explored differences in attrition rates that occur based on recruitment strategies (e.g.,
clinical trials vs. commercially available Web sites). Research from clinical trials suggests the value of including
multiple methods of communicating (i.e., e-mail , text message) along with peer interaction / social support to
improve adherence to Web-based interventions (16,18,114). A few studies have explored program adherence
using a Web-based intervention among individuals not part of a clinical trial (81,112). Results from one study
suggest that only 4.8% of the individuals who visited the open-access Web site registered to use it, and even
among registered users, the vast majority (i.e., approximately 92%) stopped using the Web site after one
month and did not return despite e-mail reminders. This dropout rate was markedly higher compared to
participants in the clinical trial (i.e., 40% drop out by month one) who were instructed to access the same Web
site.
Another study explored dropout and retention rates for a commercially available weight-loss Web site, The
Biggest Loser, Australia (81). This Web site was advertised on The Biggest Loser, Australia TV show and
included a paid subscription plan ranging from 12 weeks to 52 weeks. When looking at data from those who
paid for the subscription, the number of participants returning after the first month to use the Web site
dropped to fewer than 50% of the eligible participants by weeks 9–12 of the program among those who signed
up for a 12-week subscription. Among participants who signed up for a 52-week subscription, nonuse rates
increased the most during the first 16 weeks of the program, with a relatively steady rate of nonuse of
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approximately 60% occurring from week 21 onward.
Web sites need to be designed with content easily accessible at all page levels of the site. One study
explored what factors (e.g., demographics, self-determination beliefs) predicted surfing depth in a physical
activity and nutrition behavior change Web site (51). This study highlighted a variety of good practices for the
development of a Web site. From a design standpoint, the researchers did a small prototyping phase with a
small sample of the target population. In addition, participants determined how difficult (i.e., how many
clicks) it was to get to various information within a Web site, thus aiding in understanding how the structure
of the information impacts use. As a result, the researchers gathered a great deal of valuable metrics for
understanding user behavior (e.g., number of clicks, time spent on each page—information that can be
gleaned using tools like Google Analytics). Findings from this study suggested that the Web site had an
average penetration of only two layers (i.e., two additional clicks to content areas beyond the home page),
which is lower than the four to eight clicks more commonly observed in other successful Web sites. Although
e-mail reminders were shown to help increase the depth of exploration, the results were considered largely
inconclusive based on the relatively small depth that participants entered into the Web page.
The aforementioned studies highlighted that use of these Web site interventions was higher among the
highly educated, the overweight, and women (19,80,112). An interesting opportunity for practitioners is the
development of intervention Web sites that work more effectively among other population segments,
particularly men—which has been highlighted more generally within physical activity promotion research
(87,113).
With regard to promoting behavior change, a variety of theories have been used when developing Web-
based interventions, with the most effective Web-based interventions using Social Cognitive Theory, the
Transtheoretical Model (see Chapters 1 and 4), and/or the Theory of Planned Behavior (16,115). In addition,
although results are inconclusive, physical activity interventions that frame information based on tailored
messages, gain-framed messages, and to improvements self-efficacy appear to hold the most promise for
improving physical activity (67). Two qualitative reviews have each identified five key components to effective
weight-loss intervention Web sites. One suggested self-monitoring, counselor feedback and communication,
social support, use of a structured program, and use of an individually tailored program as key components
(56). The other review concluded that intervention developers should aim to re-create the human experience,
personalize it to the individual, create a dynamic experience, provide a supportive environment, and build
upon sound behavior change theory (9) (see Chapter 3). As can be seen, common parallels between these two
studies are a focus on personalizing/tailoring, social support, solid communication techniques, and
structured/evidence-informed/theoretically based programs.
Evidence for Interactive Voice Response (IVR) Systems
Several studies suggest that telephone-based interventions delivered by humans can be widely disseminated
and result in improved physical activity (30,117). Researchers have also explored the use of interactive voice
response (IVR) systems (also known as automated telephone-linked computer systems) as a health care tool
(85). These systems have high potential value because they can be used for simple tasks such as appointment
reminders and for complicated tasks such as delivering fully automated advice and feedback about physical
activity as well as other health behaviors. A meta-analysis of IVR telephone systems showed that automated
calls were effective at promoting improved processes of care (e.g., coming to appointments) and disease states
(e.g., improved glycemic control) (69).
Although there is limited research on IVR systems for promoting physical activity, several results have been
promising (59). For example, the most rigorous study to date examining the utility of IVR telephone systems
showed that an automated phone system was more effective than an attention control condition at promoting
physical activity for 12 months and was equally as effective as a human-delivered telephone counseling
program (59).
Some studies have identified characteristics that improve IVR user acceptance. Specifically, IVR systems
are less accepted when: (a) similar content is repeatedly given, (b) interactions are inflexible and feel driven by
the needs of the computer rather than the user, (c) users feel like the system is condescending, (d) the IVR
system makes the users feel guilty, (e) little introduction leads to poor perceptions of the system, including the
perception that the system is a telemarketer, and (f) intervention content was not delivered quickly enough
(3,33,42). Several studies have also identified ways to improve IVR systems. For example, IVR systems that
were generally accepted included a detailed description of the IVR system prior to its use, and a chance to
contact a human if problems arose with the program (42,59). Interestingly, some participants expressed a
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strong affinity for the automated voice akin to that of a mentor or close friend (54).
As with other technology systems, there are several companies who have already developed the basic
architecture for IVR systems. Development of an IVR system often involves contacting these companies and
working on developing appropriate content, including a specific set of decisions and rules about the
appropriate times to call.
Step-by-Step
Table 6.2 summarizes key steps to take when developing an electronic media intervention. Although Table
6.2 begins with similar preliminary steps identified in Table 6.1, Table 6.2 includes additional development
steps such as developing prototypes, iterative development cycles, and user testing that are critical for building
interactive electronic media programs.
TABLE 6.2 Steps in Developing an Electronic Media Intervention
Step Key Questions and Tasks
1. Identify the Who will use the system? What behaviors will be promoted?
user group.
What are the known constraints? Be as specific as possible.
2. Observe. What is the potential user currently doing related to the behavior? Why? Among those doing well, why are they
doing well? Among those doing poorly, why?
3. Identify Which theories of behavior change fit best with the issues observed with the group? Which theory has the most
theory(ies). empirical support? What does current theory not include that was observed?
4a. Develop Develop potential ideas. Highlight differences and come up with competing hypotheses.
prototypes.
4b. Test users. Concept phase: Goal is to see if how you defined your concept is how potential users see it. Show prototypes and
observe if they are “getting it” as expected.
User experience: Goal is to identify the simplest, most intuitive means of moving through the system. Observe how a
participant moves through a system focused on trying to understand expectations of the user. Note the full system
does not need to be functional (e.g., the backend storage and data processing) to get a sense of user experience.
Functional Prototype: Put it altogether, including the back-end and see if it works as planned. Previous steps will
help to minimize painful lessons.
4c. Iterate Aggregate lessons learned from user testing and go back as far as step 1 but likely 4a, depending on the results.
During iteration, the goal is to move from concept prototypes to user-experience prototypes to fully functional
prototypes.
5. Test system When the fully functional prototype is up and running, have several folks, including individuals who may not be your
among user testers but may be knowledgeable and around (e.g., colleagues) to use it to help identify obvious bugs in the
“experts.” system. Iterate based on lessons learned.
6. Test within a Goal is to identify other glaring problems with the system.
small sample
group.
7. Launch the Be prepared to monitor the system while it is going and to fix/iterate problems that arise, particularly by monitoring
system (but system use via tools such as Google Analytics.
remember to
monitor and
update).
Case Scenario 6.2
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Pavel Ignatov/Shutterstock.com
You are developing an intervention to increase walking and strength training for older adults who are
caregivers of frail spouses.
Gender: Mostly women

Age: 65 and over
You begin by observing older adults using Web pages in their homes and conduct interviews with
them about opportunities for being active. This lets you “walk a mile in their shoes.” Next, you decide
that you want to include theory-based behavior change strategies such as self-monitoring, goal setting,
and framing information in a gain-focused manner. Afterward, you begin the process of developing
prototypes and user testing. In the concept phase, you mock-up several drawings and text descriptions of
different goal setting formats. When you show participants the different goal framings, you find out the
wording does not elicit the concept you intended and you have to go back and create new paper
prototypes for goal setting. In the user experience phase, you test different self-monitoring formats by
exploring ease of use and observing how users enter their information into the system. When a fully
functional prototype is built, you have new users test the systems for longer lengths of time. In addition,
you invite several colleagues to try the system for a few days, and they find several instances of system
crashes, incomplete links, and poorly worded content. These errors are corrected and another group of
users test the system. These users respond with general interest to the Web site but feel some parts are
cumbersome. You revise the user interface to conform better to the users’ needs. At this stage, your
system has been well vetted, and your IT team can continue to monitor and resolve minor problems to
maintain your Web site.
TEXT MESSAGING
Short-messaging services (SMS; also known as text messaging) is an inexpensive, instantaneous form of two-
way communication that transmits brief written messages via a mobile phone. It is the most widely available
and frequently used mobile data service (66,104). Almost everyone in the U.S. has a cell phone, with 302.9
million wireless subscribers as of Dec 2010 (i.e., 96% of the total U.S. population, with over 26.6% in wireless-
only households; www.ctia.org). In addition, 98% of cell phones worldwide have SMS capabilities with 187.7
billion monthly text messages sent in the U.S. The popularity of texting may even increase as cell phone
companies are increasingly including unlimited texting in calling plans. What makes mobile phone technology
unique compared to other forms of communication, such as landlines or the Internet, is that mobile phone
ownership and the use of cell phones is as prevalent among those from lower socioeconomic groups as among
those from the general population (60,121). SMS is often used for “push” technology, where information is
transmitted to a user without the user having to initiate the request. Push technology contrasts with other
mobile technology that may require a “pull” from a user, such as calling a telephone number or accessing an
Internet Web site. Pull technology is also used in SMS when messages ask the user to respond or when the
user initiates dialogue to receive information. Push and pull technology and other features of SMS may be
particularly useful to help individuals make healthful lifestyle decisions made continuously throughout the day,
such as reducing screen time or engaging in a daily workout.
Using SMS for promoting health behavior is a rapidly growing area (35,62) as mobile phones have many
capabilities that can be used for health promotion (88). SMS technology can collect and deliver time- and
context-sensitive information in succinct messages that can be read discreetly. These messages are
asynchronous—that is, they can be accessed any time or place convenient for the user. The messages will also
be stored on the phone even if the phone has been turned off, and messages will be delivered when the phone
is turned back on. SMS technology can reach rural areas or places with limited cellular service because it
requires a lower bandwidth compared to phone calls made with mobile phones. These SMS features can be
useful for a wide variety of health behaviors and conditions, such as simple appointment reminders or
complicated tasks like weight loss counseling (88,89).
One of the reasons SMS is effective at promoting health behavior is that many SMS features relate to
important constructs in behavior change theories such as cues to action, reinforcement, goal setting, goal
reminders, and feedback. In addition, research has shown that SMS programs improve social support (40),
self-monitoring (99,100), perceived control (49), anxiety (93), and self-efficacy (40) (also See Chapter 3).
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Evidence
SMS has shown to be effective at improving many health-related behaviors such as diabetes management
(39,40) and smoking cessation (15,94). To date, two studies focused on physical activity have shown positive
results. In a nine-week trial conducted by Hurling and colleagues (49), 77 healthy adults received access to an
interactive Web site with a feedback facility, wrist accelerometers for self-monitoring, and tailored
supplemental messages. Participants choose to receive the messages by either e-mail or SMS. These messages
offered participants solutions for perceived barriers and included scheduled reminders for weekly physical
activity. This text message program helped increase moderate-intensity physical activity by approximately 2.25
hours per week. In another study conducted by Shapiro and colleagues (100), 58 children and their parents
used SMS to self-monitor physical activity levels for 8 weeks. After three 90-minute educational group
sessions, the children and parents were instructed to send two messages a day denoting their physical activity,
and for each message they received automated SMS feedback. The results showed that using SMS improved
adherence to self-monitoring physical activity. However, a third study by Newton (83) did not find that SMS
was effective at increasing physical activity. In this 12-week trial, 78 adolescents received a pedometer and
generic motivational messages to increase step count. The results showed that sending text messages to
adolescents decreased step count and did not change BMI. The null results found in this SMS trial may be
because of to the use of generic messages rather than tailored messages.
Other SMS research has been conducted where physical activity was not the primary aim in the trial, but it
was incorporated into the program. Four of these studies, which focused on weight loss as the primary aim,
sent diet and physical activity messages to participants. In a study conducted by Joo and Kim (52), a weight
reduction program that included access to a public health center and pedometers, printed materials, an initial
nutritional assessment by a registered dietician, and SMS, helped participants lose 1.6 kg of weight in 12
weeks. Patrick and colleagues (89) found that their SMS program, which was supplemented with brief
monthly counseling calls and printed materials, helped decrease participants’ weight by 2.88 kg in 4 months.
Haapala and colleagues (44) found that their SMS program, which did not include supplemental intervention
strategies, decreased participant weight by 4.5 kg in 12 months. Gerber and colleagues (41) also conducted an
SMS-only weight management program that focused on perceptions of use and found that women receiving
text messages about weight loss had positive attitudes toward the incoming messages. Two studies focused on
Type 2 diabetes control and incorporated physical activity messages into the program. Both of these studies
were primarily SMS-based and were supplemented with a Web site. At 12 months, both studies (57,120)
showed that SMS improved HbA1C among other measures related to diabetes control. With the exception of
only one study, all of the aforementioned SMS research conducted has shown that SMS is effective at either
improving physical activity levels or assisting in health promotion related to physical activity.
Frequency of text message transmission and duration of the program are important program characteristics.
In general, frequency of messages usually reflects the expected frequency of the target behavior (35). For
physical activity SMS studies, frequency varied greatly among the different programs. One study with a
physical activity component showed success with sending up to five messages a day (89) and others found
success with weekly messages (41,49,52,57,120). Another study left it up to the participants to decide on the
number of text messages they wanted to receive (44). As for the duration of the program, most of the
successful physical activity or health promotion studies were between 6 to 12 months.
It is important to note that SMS programs are often combined with other intervention strategies or
materials, such as interactive Web sites, a paper diary for self- monitoring, consultations with health
professionals, or printed materials. All of the physical activity SMS studies have included supplementation in
their programs. Most common was use of Web sites (44,49,57,120), counseling calls (41,89), or interaction
with health professionals (57,120).
Step-by-Step
There are many companies that offer SMS services available to individuals or businesses. One of the most
popular health SMS-based programs available to individual consumers is “text4baby” that offers women
support through pregnancy. To date, there are no SMS programs for physical activity commercially available
to individuals, but some companies offer these programs to businesses. For instance, Santech Inc.
(www.santechhealth.com) is one company that offers tailored mobile phone diet and physical activity-based
programs, such as “Text4Diet” that is a program geared toward weight loss in the general adult or teen
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populations.
There are also ways to create your own SMS programs for clients. After deciding on what SMS program
characteristics are a good fit for you and your client (e.g., personalization, interactivity), you can search online
for companies that offer bulk-messaging services. Many of these programs are free (e.g., Google Voice) or
have a small fee per message sent (e.g., www.bulksms.com; callfire.com). These Web sites offer many
advanced features that make sending general nontailored messages simple and effortless because you can easily
create address books, automatically schedule messages, track message delivery, and much more. See Table 6.3
for tips on how to write an effective text message. See Table 6.4 for sample physical activity messages.
TABLE 6.3 How to Write an Effective Text Message
What to Why Example

Include
Positive • Attention grabbing • Using words like “happy,” “sweet,” or “nice”

affect • Message becomes more salient
• Increases feedback
Gain- • Persuasive • Framing message in terms of benefits rather than

framed costs of physical activity
Nonverbal • Readers better interpret the message • Vocal spelling: “weeeeelllll”

cues • Increases socio-emotional appeal • Lexical surrogates: “mhmm”
• Using playful language creates a friendly, informal, • Spatial arrays (emoticons)
conversational tone and in turn fosters relationships
• Manipulation of grammatical markers: indicate pauses (….),
express exclamation (!), or signal tone of voice (SHOUT)
• Minus features: an absence of certain language standards
present in normal writing, such as a lack of -capitalization at the
beginning of a sentence
Powerful • Attention grabbing • Powerful: “always” or “never”

language • Message becomes more salient • Powerless: “sort of,” “maybe,” tag questions (“isn’t
it?”), hesitations (“um”), intensifiers (“really”), or
fragmented sentences
Clarity • Less mental processing effort • Regular text supplementation (only when completely
• Less distraction necessary)
• Pictures
• Animation
• Audio
• When using shortcuts, shortening words (e.g., “wk”
for “week”) is clearer than respelling (e.g., “c u” for
“see you”)
TABLE 6.4 Physical Activity Text Message Samples
Education
By exercising as little as 30 min a day, you can improve your health and live longer!
Physical activity boosts mental wellness—It can increase relaxation, concentration, and happiness
Strategies
Start with a small physical activity goal and commit regularly
Use variety to keep your interest up. Walk one day, swim the next, go for a bike ride on the weekend
Tips
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The simplest change you can make to improve your heart health effectively is to start walking. It’s enjoyable,
free, easy, and great exercise
Look for chances to be more active during the day. Walk the mall before shopping or take the stairs instead
of the escalator
Reminders
Remember to put on your pedometer today!
Grab a friend and go for a 30 min walk before the day is over
Motivational
The time to get moving is NOW!
Stick to your goal of getting 12,000 steps on your pedometer today. You can do it!
Case Scenario 6.3
Mike Flippo/Shutterstock.com
This case scenario presents the use of tailored, one-way messages to serve as prompts and cues to action.
Client: Brian
Client information:
• 18-year-old male
• A high school cross-country runner
Brian has asked you to help him prepare for cross-country team tryouts in the fall.
After designing a workout for him, you want to send it via SMS daily reminders so he can easily stay
on track throughout the summer. One tailored, one-way pushed message each day will serve Brian’s
needs. See Table 6.5 for sample text messages that could be sent to Brian to help him prepare for the
upcoming cross-country season.
TABLE 6.5 Sample Text Messages for Brian’s Cross-Country Running Training
Day Text Message
Monday Hi Brian- today’s workout: 45 min tempo run. It’s hot outside today- remember to hydrate
Tuesday Brian, today’s workout is 60 min interval training (10 x 400m)
Wednesday Today’s workout: 30 min easy with 15 min extra stretching. Keep up the good work, Brian!
Thursday Hi Brian- today’s workout 45 min Fartlek; incorporate at least 3 hills
Friday Today’s workout is 45 min interval training (5 x 1000). Brian, get to the track before 4pm, it
closes at 6pm today
Saturday Brian, here is today’s workout: 10k long run. Remember to run at a conversational pace
Sunday Good job this week, Brian!
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Case Scenario 6.4
AlexandreNunes/Shutterstock.com
This case scenario presents the use of tailored, two-way messages that serve as personalized feedback,
social support, and goal setting.
Client:Megan
Client information:
• 35-year-old female
• Employed full-time, married, two children
• Overweight (BMI = 29)
Megan’s doctor recommends that she exercise at least 30 minutes a day to lose weight. She has come
to you for help, and she does not have time to come in for counseling because of her busy schedule. Two
tailored, pushed messages each day will serve Megan’s needs. Some messages will also need to be
interactive to uncover Megan’s personal barriers to meeting her exercise goal. See Table 6.6 for sample
text messages that could help Megan exercise at least 30 minutes a day.
TABLE 6.6 Sample Text Messages to Help Megan Exercise 30 Minutes a Day
Day Text Message
Mon Megan, what is preventing you from exercising 30 min a day? A) I forget B) I don’t have time C) It’s too hard D)
AM Something else (Megan answers B)
Mon Breaking up your physical activity into 3 ten-min sessions throughout the day will give you the same benefit as doing 30
PM min at one time
Tues You can do little things throughout the day to increase your physical activity-like taking the stairs instead of the elevator
AM
Tues Combo physical activity with time spent with your friends/family. Take walks together or just play at the park
PM
Weds Hi Megan- How much physical activity did you do yesterday? A) <30 min B) 30 min C) >30 min (Megan answers A)
AM Megan, you should aim for at least 30 min of physical activity per day. Try again tomorrow :)
Weds To increase your daily physical activity, try incorporating walking meetings outdoors with coworkers
PM
Thurs Need more time in your day to get a workout in? Put your gym clothes in your car in the morning—you’ll be ready to
AM go after work
Thurs Try wearing wrist weights as you do chores around the house—this is a great way to combine exercise and chores.
PM
Fri AM Hi Megan- How much physical activity did you do yesterday? A) <30 min B) 30 min C) >30 min (Megan answers B)
Good job, Megan! Keep up the good work. Try increasing your workouts by 5 min tomorrow
Fri PM Increasing your physical activity is easier if you can distract yourself. Try chatting with friends while you walk or put on
your favorite music
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Limitations
Although SMS offers many valuable features that can be used for promoting physical activity, there are
limitations with this technology. First, the main limitation is that information sent via SMS must be brief
because each message must be 160 characters or less. Senders may send multiple messages at once, but because
of the small screens on cell phones, lengthly messages are difficult to read (e.g., surveys). Second, there is
usually a time commitment to set up an SMS program (e.g., writing messages, importing mobile phone
numbers). Third, some messages may not be received because of disconnected mobile phone or full in-boxes,
but messages are usually received when the phone is in service again. The SMS program also can be disrupted
if the cell phone is lost or stolen. However, the same limitations exist with other forms of communication
such as the postal system. Fourth, using SMS technology may marginalize certain populations, such as those
who are illiterate or do not have access to a mobile phone for financial reasons; however, these limitations will
be reduced as mobile technology advances (incorporating voice response systems or sending pictures instead of
texts) and the total cost of cell phone ownership decreases. Finally, using SMS for health promotion is in an
early stage of research, and there are still many open questions on best practices for effective behavior change.
SOCIAL MEDIA
Social networking sites (e.g., Facebook, My Space) are a type of social media comprised of personal Web
pages that facilitate communication with other users. On these Web pages, users build online profiles, and
share updates about themselves, including photos and links to their favorite groups or events, and comment
on others’ updates. A key feature of these sites is that users can link to others’ profiles, which is how the social
network develops (31). Users can choose from thousands of different health-related groups and applications
that interest them (e.g., Diabetes Daily, Ultra Running, and National Health and Wellness from Facebook).
These sites can educate, engage, and empower clients and health professionals because they offer a source to
learn about health issues and interact with a community of individuals with similar interests. Social
networking sites are one of the most popular forms of social media (98) and, as such, they have great potential
to advance health promotion.
Over the last 5 to 10 years, social networking sites have become one of the most popular sites to visit on the
Internet. As of November 2010, 93% of teens (12 to 17 years old) were online, and of these users, 73% used a
social networking site. Adults (>18 years old) were not far behind with 77% online, and of these users, 61%
used social networking sites. Furthermore, 80% of all daily Internet users visit social network sites
(http://pewinternet.org). Although young adults are still more likely to access social networks sites, the fastest
growing demographic of Facebook users is older adults (>65 years old)—three times as many older adults
signed up for Facebook in May 2010 than in May 2009 (119). Also, social media use in the United States is
independent of education, race/ethnicity, or health care access (21). As social network technology advances
and access increases, it is anticipated that the popularity of online social networking will continue to grow
worldwide (48).
The popularity of social networking sites can be attributed to their many unique features. Not only are these
sites easy to use and cost effective (i.e., most are free), but they are also user-controlled and generated. In other
words, social media sites are not static: They are interactive or users publish their own content and comment
on other peoples’ content. These sites are also easily accessed because they can be adopted on a variety of
devices (e.g., computer, mobile phone, electronic tablet). Social network sites differ from other online
communities because of their ability to enable users to display their social networks. This unique feature of
visually displaying a list of friends accessible to others is hypothesized to result in connections among
individuals that would not have otherwise been made (13). Overall, online social networks allow users to
connect and communicate to other users more quickly and easily than other forms of social media.
The connections made through online social networks have great potential for positively influencing health
because an individual’s social environment plays an important role in many different types of health behavior
(86,116), including physical activity (6). One reason is because social networks can affect the perception of
social norms, or customary rules that govern behavior in groups of people, which is a dominant force that
shapes behavior (22). Perception of social support is another factor within an individual’s social environment
associated with more positive health behavior and health outcomes in general (110). In addition to affecting
an individual’s social environment, online social network sites also allow access to information and resources
(91), which has been shown to increase empowerment (38,70). Empowerment plays an important role in
supporting behavior as individuals seek positive health behavior and lifestyle changes (4,5). Taken together,
these psychological constructs can have a powerful impact on individuals’ health behavior and outcomes.
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Evidence
Research on the use of social networks for health promotion is limited, but evidence is growing especially in
the area of health communication. In a Facebook study regarding diabetes, researchers found that about 65%
of posts included unsolicited sharing of diabetes management strategies, more than 13% of posts provided
specific feedback to information requested by other users, and almost 29% featured an effort by the poster to
provide emotional support to other members of the community (43). In another study that focused on breast
cancer survivor groups on Facebook, researchers found that this social network site had over one million
members and 620 groups. Within these groups, 44.7% were created for fundraising, 38.1% for awareness
(about 900K members), 9% for product or service promotion related to fundraising or awareness, and 7% for
patient/ caregiver support (65). These studies demonstrate that Facebook provides a forum for many different
types of health communication, from reporting personal experiences and receiving feedback to reaching mass
groups of people for awareness of important public health issues.
To date, one health behavior change intervention has used online social networks. In this physical activity-
based Facebook intervention, researchers evaluated StepMatron—a Facebook application designed to provide
a social and competitive context for daily pedometer readings to motivate physical activity (37). Researchers
found that participants who used the Facebook application to record steps had logged more steps than simply
recording steps without the social context. Although more research needs to be conducted in the area of
behavior change and social networking sites, the findings from the StepMatron study offer encouraging results
that demonstrate the potential of online social networks to motivate behavior change (37).
Step-by-Step
Table 6.7 is a list of some popular social networking sites. Peruse these sites and see which ones have the
features and functionality that meet your needs. From the Practical Toolbox 6.1 recommends other resources
to consult for more in-depth step-by-step information.
TABLE 6.7 Some Popular Social Networking Sites
Social Network Site Description
Facebook: The largest general social networking site worldwide

http://www.facebook.com
My Space: Entertainment (music, movies, celebrities, TV, and games) social networking site
http://www.myspace.com
Linked In: Business and professional social networking site

http://www.linkedin.com
Hello Health: Social networking site that connects health care providers and individuals through
http://www.hellohealth.com e-mail, instant messaging, and video chat
Dlife For Your Diabetes Life! Diabetes patients, consumers, and caregivers social networking site
http://www.dLife.com
Athlinks: Race results and social network for endurance athletes

http://www.athlinks.com
Twitter: http://twitter.com A social networking and micro-blogging service utilizing instant messaging,
SMS, or a Web interface
FURTHER RESOURCES FOR USING SOCIAL MEDIA SITES
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For more in-depth step-by-step directions, many books are available, including the following:
• The Twitter Book by Tim O’Reilly and Sarah Milstein
• From Facebook to Twitter and Everything in Between: A Step-by-Step Introduction for Social Networks
for Beginners and Everyone Else by Todd Kelsey
There are also many more business-related features on Facebook to help grow your business and
build your client base, such as adding Facebook to your Web site. To learn about these features and
many more, there are books available that focus on using social networks for professional use,
including the following:
• Reaching Your Online Community with Face-book, LinkedIn, and More by Tom Funk
• Doing Business on Facebook by Vander Veel
Most social media sites also have a user-friendly step-by-step guide on how to get started on their
sites and how to use more advanced features, such as the following examples:
• https://support.twitter.com
• http://developers.facebook.com
FACEBOOK
Facebook is arguably the most popular social networking site and can help you reach out to existing or
potential clients. Many of the Facebook features described here, such as pages and groups, are also features on
other social networking sites. Therefore, much of the information covered in this section applies to other sites
as well.
• Pages: A “page” is a collection of information about a person, business, or organization. To be a member
of Facebook, you need to set up a profile page—it can be a personal and/or professional page. Potential
clients can find you by viewing your profile and vice versa. (Tip: You can include a link to your business
Web site or other Web sites you think your clients will find useful.)
• Networks: A “network” is a group of people with a real-world connection but who might not know each
other (e.g., people who are connected through a common school, region, workplace). You can browse
through profiles of people in your network to look for potential clients based on various kinds of
information, such as age or specific interests. Likewise, others in the network will be able to find and
connect with you for your services. The introductions made through your network are safer and less
awkward than introducing yourself to people to whom you have no known connection.
• Groups: A “group” is a collection of people with the same interests (e.g., clubs, companies, public sector
organizations). Groups are a way of enabling a number of people to come together online to share
information and discuss specific subjects. You can join one or start your own. This is a great way to
network new clients (e.g., participate in industry-related groups, events, discussions) or communicate
with current clients (e.g., send messages, exchange ideas, set up meetings).
• Events: An “event” is similar to a group, but users RSVP to in-person events. Advertising or promoting
an event through Facebook is a quick and easy way to invite many people at once. For example, you
could create an event for Ride Your Bike to Work Day and send invites to your clients.
• Newsfeeds: A “newsfeed” is a constantly updated list of the things your Facebook friends are doing on
the site (e.g., adding applications, attending events, writing on Walls, commenting on notes and photos,
befriending each other). This feature enables you to catch up quickly up on your clients’ recent activities.
• Marketplace application: This application lets you post and answer want-ads. You can use Marketplace
to advertise your business or find those who are looking for a health professional. This application is
unique because you can view someone’s profile before you contact him or her to conduct business, which
makes the transaction safer than want-ad advertisements from the newspaper or sites like Craigslist.”
TWITTER
Twitter is another popular social networking site. Twitter is similar to Facebook in many ways, such as users
have profiles, it streams updates, and you can meet new people through networking. However, Twitter focuses
on communication via short messages of 140 characters or less called “tweets.”
• Tweet: “Tweets” are similar to text messages because they are short, concise, easy to read and write
messages, but they are sent and received in real-time and can be sent through a variety of channels (e.g.,
computer, phone, tablet). You can choose to have your tweets be public or private.
• A following: On Twitter, you choose whose messages you want to subscribe to or follow. You can ask
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your clients to follow you on Twitter to distribute exercise ideas/comments or news about organized
events. Likewise, you can also follow your clients—for instance, you can monitor their physical activity
or weight loss progress through their tweets. (Tip: The great thing about Twitter is that you can choose
to send public messages and, as such, potential clients can view your conversations with current clients.
This offers the opportunity to promote your business because potential clients can see your
responsiveness or customer service toward current clients.)
• Links: Twitter can be a way to refer potential or current clients to your other sites (e.g., business profile,
blog, Facebook page) by posting the link with a creative headline.
SOCIAL NETWORK GROWTH

Whichever social media site you use, the success of your page or group will depend on the social network of
people who develops around it. Social networking is about sharing and interaction, so it is important to create
a following of users—the more users you have, the faster the social network will develop (53). To create a loyal
following of users, the content in your site should be constantly updated so it remains interesting and
engaging to your target audience. The more engaging the site, the more users will suggest to other friends to
like or subscribe to your site. As a result, your network will grow. Focus on long-term relationship building
strategies such as observing the culture and dynamics of the online community that you join. Research what
your target audience is interested in and what they find interesting, enjoyable, and valuable (53). Do not be
discouraged if at first the response to your site is slow, as you need time to develop a following. See section
From the Practical Toolbox 6.1 for more information on social networking tips and strategies (31). Also,
From the Practical Toolbox 6.2 provides cautions to health professionals using social networking sites.
Case Scenario 6.5
JCREATION/Shutterstock.com
This sample scenario presents the use of Facebook and Twitter for physical activity promotion. The
scenario demonstrates how Facebook and Twitter can offer individuals social support, provide
perceptions of social norms, and influence feelings of empowerment.
Client: Daniel
Client information:
• 33-year-old male
• Diagnosed with Type 2 diabetes mellitus
• Obese (BMI = 31)
Daniel has come to you for help to increase his physical activity levels. He’s been feeling depressed lately
because of his disease and has lost the motivation to exercise. You suggest that Daniel join Diabetes
Daily, an online support group on Facebook for diabetic patients. See Figures 6.1 through 6.3. You also
suggest that Daniel follows Everybody Walk, a walking group on Twitter. See Figures 6.4 and 6.5.
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FIGURE 6.1.Facebook Group, Diabetes Daily. (Reprinted with permission from Diabetes Daily.)
FIGURE 6.2.Sample post from the Diabetes Daily group. (Reprinted with permission from Diabetes Daily.)
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FIGURE 6.3.Sample comments on Diabetes Daily from Daniel and other group members (edited for privacy). (Reprinted with
permission from Diabetes Daily.)
FIGURE 6.4.Twitter group, Everybody Walk. (Reprinted with permission from Every Body Walk.)
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FIGURE 6.5.Sample posts from Everybody Walk. (Reprinted with permission from Every Body Walk.)
CAUTIONS WHEN USING SOCIAL NETWORKING SITES

When using social network sites as a health professional, there are important considerations to
remember.
1. You must remain professional at all times. Be aware that pictures or information you post could
be seen by clients and could promote the distortion of boundaries and compromise trust between
you and your clients (64). It is recommended that you set up a separate page for your professional
use independent of your personal page or use the privacy settings on your personal page (e.g., be
selective of who is viewing photos/videos that others “tag” you in).
2. Be mindful of the legal issues surrounding sharing personal information — most importantly, be
sure you are in compliance with the Health Insurance Portability and Accountability Act
(HIPAA). There have been reports of lawsuits against health providers because of private
information appearing on public Web sites (47,76). To be safe, you can guard against hackers by
checking if the site is adequately protected against those who may get access to private
information.
3. Individuals may misinterpret your online comments (31). In online communication, an array of
cues frequently used in face-to-face communication will be absent, such as voice inflections and
body gestures. If you need to communicate particularly important or sensitive issues, traditional
forms of communication (e.g., phone calls, office visits) may be more appropriate. In general, you
should conduct yourself on social network sites as you would in real life, and remember that
mishaps can travel fast through your online social network.
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PHYSICAL ACTIVITY MONITORING DEVICES
The modern-day health and fitness professional has a distinct advantage over previous generations: the ability
to use sensor systems to monitor health behaviors and the outcomes of their clients and give feedback about
this information to the client. These kinds of feedback loops can help tailor program goals and keep clients
motivated. Sensor-based devices for health behavior monitoring have proliferated over the last decade because
of the rise of cheap microelectromechanical systems (MEMS) and rapid improvements in data analytics.
Previously if an individual wanted to measure their physical activity or exercise, he or she had to rely on pen
and paper, stopwatches, or simple mechanical pedometers. Today, anyone who wants to track their workouts
or daily activity can choose from a variety of different tools to meet their needs (also see Chapter 2).
Monitoring devices can be a key component of a physical activity program that integrates objective
measurement for self-monitoring with information feedback for motivation. This section will describe some
of the common sensor systems that can be used to measure, track, and change health behaviors. We will focus
mostly on physical activity behaviors, as those sensor systems have been the most widely developed in recent
years.
Evidence
PEDOMETERS
Currently, the most common method to determine the extent of daily physical activity is a pedometer.
Pedometers are worn on the hip and display the total steps taken for a day, and in some cases the amount of
time a person spends moving. The low cost and ease of use make pedometers an ideal tool for a wide range of
individuals wishing to start a physical activity program and track their progress. Pedometers do have
important limitations that have been addressed by more sophisticated sensing technologies. These limitations
include issues related to the accuracy of derived step counts, the inability to discern intensity of movement,
and the lack of daily energy expenditure information (108).
Current public health recommendations call for 10,000 steps/day for able-bodied adults, 11,000 for female
children, and 13,000 for male children (President’s Council on Phyis-cal Fitness and Sports, 2002; Hatano,
1993). As with all exercise and activity programs, it is important to take into account the activity and health
history of the individual before providing numerical step guidelines (109). A pedometer allows individuals to
understand and work toward these activity recommendations. Numerous studies have showed that pedometers
are an effective tool for increasing physical activity in adults and youths (17,71). Intervention and
observational studies have indicated that the pedometers use can lead to a daily increase of approximately
2,000 steps/day (17) and moderate weight loss (92). It should be noted that pedometer interventions were
more effective when used in conjunction with a self-tracking program (e.g., daily step diary), goal setting tied
to daily step counts, and when study participants were mostly sedentary at the onset of the intervention. One
of the most widely validated low-cost electromechanical pedometers is the Yamax Digiwalker series, which
has been shown to be highly accurate (+/− 1%) for assessing step counts (27). One caveat of using
electromechanical pedometers is the effect of speed of movement on accuracy. Walking at slower speeds (< 3.0
mph) may not produce the force required to trigger the mechanical lever, and therefore the pedometer will
underreport the number of steps (27). This is an important consideration when choosing devices for
individuals who are inactive or are of older age.
It is important to note that many modern pedometers use accelerometers instead of electromechanical
mechanisms to more accurately assess step counts. Both the New Lifestyles (NL series) and the Omron HJ-
710 ITC are validated accelerometer-based pedometers (26,27,45) and have been used in physical activity
interventions. These devices are not without drawbacks, as they tend to overestimate energy expenditure (27).
A recent study of free-living individuals showed that the Omron pedometer may underestimate steps because
of a 4-second filter, which limits the recording of steps to only bouts lasting longer than 4 seconds (101).
ACCELEROMETERS
The proliferation of low-cost accelerometers has changed rapidly the ability of pedometers and other similar
sensors to measure human movement. Accelerometers are usually small microchips that contain systems for
measuring the gravitational force (g-force) acting on the device. It is important to note that each sensor will
have a specific sensitivity to detect a certain range of g-force. Typically, accelerometers measure g-force along
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a given axis. Uni-axial accelerometers, when oriented correctly, measure g-force along the “y” or vertical axis.
A dual-axis accelerometer includes the “y” axis and the horizontal “x” axis, and a tri-axial accelerometer
includes the “z” axis in addition to the “y” and “x” axis. Measuring movement only along one axis has
limitations as only the vertical displacement of the sensor will be detected. Adding horizontal (x) and sagittal
(z) displacement can increase the accuracy of movement detection.
Accelerometers are used in combination with microprocessors in movement-sensing devices. These
microprocessors interpret the g-force readings supplied by the accelerometer. Most devices have proprietary
algorithms that take the accelerometer data and translate it into useful movement information such as: (a) the
number of steps taken, (b) the time spent moving, (c) the intensity of the movement, (d) the distance traveled,
and (e) the calorie expenditure of the user. It is important to note that accelerometers are best used when
trying to measure primarily leg-based movements that involve a ground reaction force. These movements,
such as walking and running, typically make up the majority of daily human movement (107). Movements not
captured well are water-based activities, such as swimming, and activities with little to no ground-reaction
force, such as cycling (20).
The vast amount of evidence for accelerometers for the measurement of physical activity has focused on
research-grade devices like the Actigraph models. Most accelerometers, as mentioned earlier, process the raw
gravitational signal and output time-stamped data (typically called a “count”) used to determine the activity
intensity, the time spent moving, and the time wearing the device (7). Numerous studies have been conducted
to determine the validity of different accelerometer models produced by various manufacturers. These studies
conduct “side-by-side” comparisons of the proprietary “counts” and research-derived cut-points for translating
“counts” into physical activity intensities (96). These devices, although they tend to be more accurate than
mechanical pedometers, are more expensive (> $300 for the device and software) and do not have an external
display to provide feedback to the user. Therefore, these types of accelerometers manufactured for research
purposes are rarely, if ever, used as a tool for feedback in physical activity interventions.
HEART RATE MONITORS

Heart rate monitors are one of the most commonly used activity-related biosensors. Heart rate monitors have
sensors that measure the electrical signals derived from heart muscle contraction and relaxation—termed
electrocardiography (ECG). Currently available heart rate monitors usually consist of two components, a
chest strap and a receiver—typically a watch or other display system. ECG signals can be processed and
transmitted to the receiver where the heart rate is displayed. In some cases, raw ECG signals are sent to the
receiver, and they are processed into heart rate and other variables like heart rate variability (HRV, the period
between R spikes during heart function). Heart rate monitors are an ideal device when real-time feedback
about physical activity intensity is needed. This may explain their popularity with trainers or health
professionals who are creating personalized training methods to improve the cardiovascular fitness of a client
or athlete.
Numerous studies have examined the validity of different heart rate monitors (typically manufactured by
Polar Electro) and showed the devices to be consistent with clinical ECG monitors (11,68). Many researchers
have examined the use of heart rate monitors for estimating energy expenditure and found variable but
positive results (1,25,77). The common theme among studies examining energy expenditure is the valuable
increase in accuracy when objective biometric information such as maximal heart rate and VO2 are added to
the estimation software.
Heart monitoring is not without its limitations. Typically, all-day wear of heart rate monitors is
burdensome to individuals and data quality issues arise during long-term monitoring (14). It is also important
to understand that data derived from heart rate monitoring can be affected by many different factors, such as
hydration levels, temperature, illness, and altitude (1,2).
GLOBAL POSITIONING SYSTEMS

For users who accurately want to track their outdoor activities, global positioning systems (GPS) are ideal.
Personal GPS devices are based on the same technology common in vehicle navigation systems. A small
computer chip in the device communicates with GPS satellites orbiting the earth and determines precise
location information. This location information is processed and data regarding location (latitude/longitude),
speed of travel, and distance traveled is made available. Most commercial GPS units produced for physical
activity tracking are used for running and cycling, but they can be used to track most, if not all, outdoor
activities. Although stand-alone GPS units are available, most are bundled with additional sensors to measure
heart rate or another important variables such as pedal cadence (revolutions per minute) for bicycling.
The objective data (i.e., speed, distance, pace) derived from GPS units do not differ as a function of activity
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type or individual characteristics. However, the most common concern when using GPS devices is their
accuracy. Studies examining commercial GPS units have showed them to be accurate for determining the
velocity of running and walking as well as stationary position (95,106,118). These studies have also
highlighted a few known issues that may affect data accuracy, including moving in a curvilinear manner (e.g.,
the curve of a track) and traveling at high speeds (e.g., sprinting). This is in addition to environmental factors
external to the movement type that can affect accuracy. These include traveling in or around locations with a
high number of tall buildings that can cause signal interference and traveling in locations without clear and
unobstructed views of the sky (105).
Step-by-Step
When deciding if using a monitoring system is appropriate for clients or patients, it is best first to understand
the relationships among the types of data gathered, the ability to monitor different activities, and the cost of
the devices. This information is presented in Table 6.8. Noticeably absent from this list is activity related to
strength and resistance training. Compared to aerobic activities, the objective measurement of strength
training is currently lacking, although developments in muscle activity sensing are being explored and may
prove to be useful for measurement and tracking purposes.
TABLE 6.8 Features of Pedometers, Accelerometers, Heart Rate Monitors, and GPS Devices
Case Scenario 6.6
Diego Cervo/Shutterstock.com
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Client: Jonathan
Client information:
• He is 50 years old
• Recently discharged cardiac surgery patient. He has undergone the typical rehabilitation program
administered at the outpatient clinic.
• His doctor has told him that he needs to remain active and try to lose weight.
• He is not comfortable with new technology.
• He does not have access to a gym.
Jonathan has been referred to you to develop an activity plan and stay accountable.
In this scenario, you would most likely use a low-cost pedometer and a daily step goal plan to help
encourage Jonathan to be active in his everyday life. You may find it useful to conduct a baseline
assessment to understand his current activity levels and create an appropriate plan that gradually
increases his step counts. As someone not comfortable with technology, developing a daily step tracking
sheet that he can share with you would be ideal.
Case Scenario 6.7
Iakov Filimonov/Shutterstock.com
Client: Grace
Client information:
• 35 years old
• Prefers to train indoors at her local gym.
• She is comfortable with technology.
Grace is moderately physically active and wants to increase her activity and fitness level to train for
and compete in an upcoming half-marathon. She has hired you to help her plan her weekly training
plan.
In this scenario, you would most likely recommend a heart rate monitor as the best activity
monitoring tool. She probably will be participating in aerobic activities using the treadmill and indoor
track. A heart rate monitor is the ideal tool for measuring her current fitness state and providing
feedback on activity intensity. Many heart rate monitors provide methods for downloading and saving
data to a computer or device-specific Web site. You can encourage Grace to share this data with you to
better understand if she is following the training program and determine its effect on her fitness level
and her recovery from prescribed workouts.
INTEGRATING ACROSS MULTIPLE TECHNOLOGY CHANNELS
Technological advancements such as video streaming, faster processing power, wireless connectivity, and
extended battery life and storage capacity have been key contributors in the development of many of the
previously mentioned messaging and feedback technologies. As we have presented in this chapter, there are
many different types of technologies to measure, track, and give feedback on physical activity. Different
combinations of these technologies can be found in some commercially available systems and services. These
integrated systems allow users to interact with their data, interact with other users, and receive expert
knowledge. The center point or gateway of many integrated systems is the smart mobile phone. This section
introduces the smartphone and its features as a way of integrating technologies for physical activity
interventions. We describe commercially available integrated systems, and then describe how physical activity
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and data can be shared across multiple systems to create unique and highly customized interventions.
Smartphones and Their Potential for Physical Activity Interventions

Smartphones have many capabilities that can be harnessed for promoting health (88). Beyond the basic
capabilities for two-way communication via voice or text messaging, many mobile phones have built-in
cameras, gigabytes of storage, an Internet browser, can transmit data to outside networks, and some even
include global positioning systems (GPS), built-in accelerometers, connectivity to WiFi, and wireless
communication with external devices via Bluetooth (e.g., heart rate monitors, external accelerometers). These
smart-phone features are ideal for creating an integrated intervention system.
Current evidence suggests that mobile telephones coupled with Internet services can promote increased
physical activity (49). In addition, previous research has suggested that personal digital assistants (PDAs) were
effective in increasing physical activity over 8 weeks relative to an assessment-only control (58). Some studies
have also demonstrated the potential of using the background of a mobile phone as a “glance-able display” for
providing feedback to individuals (23). Beyond this, few studies have explored systematically if these new
mobile phone features can be used to promote physical activity.
Consolvo and colleagues (24) identified eight design considerations when developing effective persuasive
technology interventions for promoting physical activity: (a) Abstract and Reflective (i.e., do not display raw
data but instead abstract that information to something meaningful to the individual and inspires reflection);
(b) Unobtrusive (i.e., have the system only be there when wanted/needed and not be bothersome otherwise);
(c) Public (i.e., representations of personal information must be done in such a way that it can be displayed in
public without making the user uncomfortable), (d) Aesthetic (i.e., to maintain use, the system must fit with a
user’s sense of style and aesthetic), (e) Positive (i.e., reward good behaviors rather than punish bad ones), (f)
Trending / Historical (i.e., provide a sense of past behaviors), and (g) Comprehensive (i.e., take into account
the key behaviors that fit into a person’s lifestyle). These design considerations are not only conceptually
important to interventions, but also can be implemented successfully with smartphones.
Commercially Available Integrated Intervention Systems

Many commercially available integrated systems typically include self-tracking along with interactive Web
and/or mobile experiences. The interactive platforms offer more flexible opportunities for Sources, Messages,
Channels, Receivers, and Feedback, which in theory should lead to systems that adapt to the user rather than
forcing the individual to adapt to the system. An ideal integrated system: (a) fosters quick and easy
communication between multiple devices (e.g., pedometers, Web sites, smartphones) with minimal to no
effort for the user; and (b) optimizes each component of the system to perform its role in physical activity
promotion without creating additional burden on the user because of technical needs (e.g., feedback is given
when and where it is needed, not where it is convenient for the system). The broader goal is the development
of systems that integrate into a person’s life and daily routine to provide added value with minimal additional
burden to the user. Much work is still needed to meet these ideals.
Current systems offer a variety of different tools and capabilities for reaching these mentioned ideals and
most often they follow a schema that involves four key functions. First, the platform allows users to upload
and view data gathered from a device or sensor system. These data are typically downloaded from the device
using a device-specific application or uploaded to a Web site wirelessly. Second, the platform provides ways to
visualize data derived from the sensors. Visualizations are meant to be highly interactive, simple to
understand, and informative, though it is important to emphasize that highly interactive does not necessarily
equate to informative (122). Third, the user can use the system to set a goal, or in some cases multiple goals,
that pertain to physical activity, diet, body weight, or sleep. The system then presents feedback to indicate
daily and/or weekly progress toward the goal. In some cases, goal attainment is attached to virtual-rewards,
such as badges and positive messages. Lastly, the majority of commercial systems have begun integrating a
social networking component into their platform. These are often manifested as the platform sending
information about the user’s behavior to social networking sites, such as Facebook and Twitter on the user’s
behalf. Some integrated commercial systems enable users to “friend” each other through the platform and
engage in friendly competitions and challenges. The most common of these methods is through providing a
leaderboard, where a user is compared to their “friends” on a common metric, such as steps per day or calories
burned.
One example of an integrated intervention system is the FitBit (Fitbit, Inc., www.fitbit.com). The FitBit is
a small accelerometer-based physical activity monitor the size of a typical flash memory stick. It wirelessly
syncs physical activity data to a Web interface when it is within range of its USB receiver, which is plugged
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into a computer. The device has a small display on it to provide feedback on steps taken, miles traveled,
calories expended, and activity history. The activity history is a glance-able display of a flower. The flower
grows when the person is active and serves as a visual metaphor for the amount of activity achieved in the last
three hours. The Web interface allows users to see their current and historical data, set goals, log activities,
and see where they rank among their friends who also use a Fitbit. The Web interface can be accessed on a
computer or smartphone. Other examples of commercial integrated systems currently available include
Garmin Connect (Garmin, Ltd.), Nike+ (Nike, Inc.), and Runkeeper (FitnessKeeper, Inc.).
Data Sharing across Systems and Technologies

Although the aforementioned commercially available integrated systems offer platforms for behavioral
tracking and messaging, the true technological strength of many of these systems is the ability to gather and
share data, which is critical for an integrated system. Many of the companies that offer physical activity
intervention products have begun offering ways for users and other application developers to access data to
create additional services or systems that potentially increase the functionality of the core platform. This is
possible by using an Application Programming Interface (API) to interact with the platform and user data.
An API is specific programming code that allows for applications to communicate with each other and pass
information back and forth. APIs allows for applications to both pull (read) and push (write) data based on
the needs of the application. For example, the popular fitness application Runkeeper (FitnessKeeper, Inc.)
allows many different applications to read and write data to a user’s profile through its own Health Graph
API. If a user has a Runkeeper profile, but prefers to use a different mobile phone–based run tracking
application, data gathered from it can be pushed (written) to the user’s Runkeeper profile. APIs are not
limited to product-application-to-product-application communication. Developers can also create their own
Web-based applications that pull in user data and use alternative methods of data visualization and feedback
that supplements and enhances the user experience. Ideally, this increased connectivity between devices allows
for a physical activity system to gather data from multiple sources, aggregate this information, and provide
feedback to an individual using the channel of choice for that individual at the appropriate time.
When a company offers an API for its product, it is saying to the world, “take our product and integrate it
with your product or make our product better.” This access and openness provides others with the opportunity
to use products in creative ways and customize products for specific needs. The proliferation of APIs offers an
exciting new way to interact with clients and patients who use integrated technology platforms in their
training or care. Working with an API requires expertise in computer programming for Web or mobile device
applications. Documentation is usually available for an API to illustrate the communication schema and what
types of data are accessible.
TAKE-HOME MESSAGE
We hope this chapter served as a useful resource with examples of what is currently possible and how
one can start to use the available technology channels to promote physical activity in people’s lives.
However, we have also raised a note of caution that the scientific evidence to support effectiveness of
tailored print and Web-based interventions for physical activity is currently limited, and research is
ongoing to determine what factors need to be included in these programs. Even fewer studies have been
conducted to evaluate interventions that use mobile and social network technologies to influence
physical activity. Using these technologies to deliver physical activity interventions is a rapidly evolving
field in both academic research and commercial settings. It is a challenge for researchers and
practitioners to keep up with the pace of technology advancements. Ideally, the science and evidence
should drive the application of the technology. These technology channels can be used to create
persuasive intervention programs by closely following the tenets of behavior change theory. Although
new and exciting technologies will continue to offer a variety of communication and persuasion
mechanisms, we caution against using such a technology just because it is new and exciting.
Although print materials will likely continue to have a place in physical activity promotion programs,
other technologies such as SMS, social networks, and mobile phone applications are likely to be more
effective tools to engage individuals daily. These technologies have the potential to transform physical
activity interventions because they are easy and convenient to use and have become integrated within
the daily lives of most individuals. Print materials can still be considered an important part of a physical
activity messaging system. Even when deploying technology-based interventions, there may be the need
to prompt individuals to refer to print or online resources for educational or review purposes. Interactive
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Web sites and Web-based interventions typically provide a location for accessing tailored information
and/ or materials for “self-paced” learning.
SMS interventions may be of particular interest as a basis for an intervention program because many
people have access to this readily used and inexpensive technology. Several studies have shown that
SMS helps individuals increase physical activity levels, lose weight, and improve diabetes control.
Similarly, online social networks have tremendous potential because they offer the opportunity to
facilitate health promotion by increasing communication and accessibility among health care providers,
patients, and others who have similar interests. Online social networks may be the ideal technology for
fitness professionals without IT support to develop custom pages or IVR systems. Having an online
social network as part of a physical activity intervention offers individuals new opportunities for
empowerment and helps shape their perceptions of social support and social norms, which are
important health behavior determinants.
It is the integration of these different technology channels that can provide individuals with a
compelling ongoing user experience for both adoption and maintenance of physical activity. Decisions
on which technology channels to use for a physical activity intervention requires a balanced
understanding of the needed skills, the resources available, and the level of customizability needed for
the development of a particular type of intervention. These factors must be taken into account when
deciding among developing a custom de novo intervention system, using previously developed devices
and systems, or customizing commercial platforms through open APIs. Mobile and wireless
technologies are a rapidly changing landscape of devices, systems, and services that will continue to offer
many possibilities for delivering physical activity interventions.
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This chapter explores the relationship between policy, environmental changes, and physical activity.
These areas of work are usually carried out by public health staff in their efforts to increase population
levels of physical activity. As such, they are concerned with getting everyone in a community or region
to be more physically active, until “health targets” are reached, with all adults and children meeting
population recommendations for health-enhancing physical activity (43). These public health actions
are far from the individual focus of physical activity counseling, individualized or small-group physical
activity programs, or other approaches to change individual behavior regarding activity. This chapter is a
link between what public health professionals do, and what individual practitioners do in their daily
work.
The objectives of this chapter are to describe the role of policies and the physical environment in
physical activity, from a practitioner perspective, rather than from a policymaker or decision-maker
perspective. This is seldom done, and the differences between practice and policy are often highlighted.
Here, we approach this chapter to minimize the artificial gulf between physical activity policy and
practice, and show how an understanding of policy and of the physical environment can help
practitioners in their work to increase activity and exercise behaviors among their clients and patients.
Terms that may be unfamiliar to some behavioral and exercise scientists and practitioners are defined in
Table 7.1.
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EVIDENCE
Physical Activity Policy

This section introduces physical activity policy actions and then presents a discussion of the physical
environment and its role in physical activity.
POLICY DEFINITIONS
Physical activity policy can be defined in three ways: (i) policy as a set of written rules or regulations, (ii) policy
as defined guidelines, and (iii) unwritten social norms (4).
Policy as a Set of Written Rules or Regulations
The most commonly used definition of policy is “written regulations or rules” that facilitate physical activity-
related behaviors. This includes rules and regulations, local municipal ordinances, and specific rules in defined
settings (27). The range of policy contexts relevant to physical activity is large—ranging from transport and
urban design policies, education policy, sport policy through to health sector policies for the health system,
primary care and prevention, and community practice. Policy examples include “mandating a specific
minimum amount of weekly physical education in schools”; or a municipality developing a possible policy to
regulate building codes, such that a “certain amount of green space is mandatory in new urban and housing
developments.” A key part of this definition of policy is to assess enforcement and uptake; how many agencies
or settings adopt and implement the “rule” will influence the impact of the policy on physical activity (45).
TABLE 7.1 Definition of Physical Activity, Policy, and Environment Terms
Term Definition
Moderate Physical activity and exercise performed at moderate intensity, such as walking at 3 mph, cycling at 6 mph, walking
physical during golf, heavy gardening, or household tasks (3.5–5.9 METs)
activity
Vigorous Higher energy physical activity or exercise, such as jogging or running, skiing, cycling > 10 mph, swimming laps, singles
physical tennis, gym classes, chopping wood, hiking uphill (≥ 6 METs)
activity
Mixed use A description of land use, where an urban or town space has a range of types of uses—people live there (residential), there
are shops, businesses, schools, public spaces and parks
Pedometer Small device, worn usually on the hip, to measure steps taken—people can observe their own physical activity in relation
to their physical activity counseling advice (“How much did I walk or how many steps did I take today?”)
Advocate This is the task of representing a position on an issue to others, to be an “advocate” for physical activity is to promote,
recommend, and support physical activity in your community, in your workplace, to your local municipality, and to other
decision makers.
Behavior The places where behavior change occurs; people could be active in different settings—it could be possible at home or at
change work or in the downtown area, but it may be easier in a park or on a trail (these are more facilitatory settings)
setting
Macro-level This refers to the physical environment or to a policy; macro level is the city or county level; micro level is your local
micro-level neighborhood; physical activity is related to both micro- and macro-level environments; for policy, a macro-level policy
policy or will impact a large city, county, or state (a micro-level policy will impact local neighborhoods or districts)
environment
Urban design How cities, towns, or public space is constructed, designed, or used can influence physical activity. Urban design is the
process of designing towns and cities to facilitate walking, public transport usage, parks, and open spaces for recreation,
and sport and active play. The planners and designers of urban space can help get communities to be more active
Aesthetics Places where people might be physically active can be appealing, relaxing, full of natural beauty, and have things to look at
—such as when walking on a trail along a river; this is the meaning of “aesthetics”—a pleasant place is nicer to run or bike
alongside, than is a freeway
Sprawl Urban sprawl is the growth of residential suburbs a long way from a town center; these suburbs require automobile
transport everywhere, are seldom “mixed use” (see earlier) and may not encourage walking for short distances in the
community (as the destinations, places people want to go, are too far away to walk)
Residential The number of houses, dwellings, apartments in a defined area; where there is medium to high density, there will be
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density more shops, schools, workplaces within walking distance, making it a more “walkable” community (the opposite of “urban
sprawl,” described earlier)
Negative Weight loss or weight gain results from energy imbalance; positive energy balance is eating more than you burn (calorie
energy intake from food is greater than calories burned through activity); negative energy balance is the opposite—move more
balance and expend more energy than you consume.
“Activity “Activity friendly” environments and communities have good facilities for walking, sport, and exercise, and may be (see
friendly” earlier) any combination of low density, mixed use, high aesthetics, that is well designed for “active living,” incorporating
physical activity into everyday life
Socio- Models of behavior change that recognize the importance of individual-level, interpersonal, social and physical
ecologic environmental, and societal-level determinants of behavior such as physical activity; and the interplay between levels of
models influence in contributing to whether a person is physically active or not.
Clinical exercise physiologists and other clinical practitioners will engage with some policy developments
more than others. Every professional providing physical activity advice should become an “advocate” for
physical activity, and should be concerned with low population rates of reaching recommended levels of
activity for health. Nonetheless, some policies will be more directly relevant to clinical counseling than others.
For example, policies that encourage workplace PA programs; others that consider health insurance subsidies
for activity programs, and provide other incentives for individuals to be active—these are directly relevant to
the behavior change setting (40). Other policies that provide information and support individuals are
indirectly important, as they may support individuals trying to change their behavior. These include the policy
initiatives that lead to community-wide programs, mass media efforts and social marketing campaigns to
inform, persuade, and encourage individuals to be more active. These are complemented by environmental
and regulatory macro-level policies around public transport, urban design, park utilization, and mandated
school-based programs. These are important for large-scale efforts to achieve population-level physical activity
and fitness changes.
An overarching model of the relationship between policy, environments, and individual behavior change is
shown in Figure 7.1. The first stage is contributing evidence to make the case; this is shown on the left hand
side of the model, and contributes a clear distillation of the evidence for physical activity. In other sectors,
physical activity may be a byproduct—for example of increased public transport systems. If more buses or
trains are available, active commuting to get to or from transport will increase (32,55), although the transport
sector policy objective is primarily growth in transport usage. If there is a clear case for physical activity, which
interests the community and political processes, then a planning process may begin to “take action” (see
Figure 7.1). The outcome of this is a national, state, or municipal/local-level physical activity plan, which has
clear accountability and targets. The development of policy is the mechanism for achieving these targets, and
may require partnerships across agencies in sport, health, education, transport, and the environment. In
addition, the private sector, nongovernment organizations, and other stakeholder groups may be involved.
Policy implementation will require commitment, a sufficient time frame, community support, and appropriate
allocation of resources (40).
Policy as Defined Guidelines
A second definition of policy is as “standards” or “guidelines.” In the context of physical activity, the
development of “physical activity guidelines” has occurred in many countries, including the U.S., and recently,
through global physical activity guidelines developed by the World Health Organization (WHO) (13). These
guidelines are developed through a thorough review of the epidemiological evidence, and result in clearly
specified amounts of physical activity required for health benefits. Separate guidelines have been developed for
children and adolescents, for young and middle-aged adults, and for older adults. These are shown in Table
7.2, adapted from the U.S. and WHO guidelines. Table 7.2 shows the counseling-relevant implications of the
guidelines, identifying some of the new messages and communications needed for practitioners. These new
messages are updated as the evidence changes, and form the basis for advice from all physical activity
practitioners.
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FIGURE 7.1. The link between policy, environments, and individual physical activity programs and behavioral counseling.
The recommendations in Table 7.2 are the key messages only. For further detail, see the original
documents (13,43). However, they have substantial implications for clinical practice. This is an example of a
guideline that is likely to contribute to adolescent health, and to childhood obesity prevention, so it is useful in
providing guidance for clinicians and counselors. Among young people, an hour of physical activity per day is
required, and this is difficult to achieve from one source of physical activity only. Hence, recommendations
imply some increases in “active living” are needed, so that children and adolescents need to be active at school,
in “active after school” programs, through school sport and physical education, and also through active
transport to and from school, where possible. Further, some guidelines specify reductions in sedentary time
(3), whereas others do not specify a threshold here since the evidence is still developing.
For middle-aged and older adults, a minimum of 30 minutes of moderate intensity physical activity for 5
days per week is the minimum recommended for health (1). This does not need to be performed at vigorous
intensity which is important in counseling. Furthermore, physical activity can be accumulated throughout the
day, in sessions of at least 10 minutes of activity (1). People who have been inactive for some time should aim
for any physical activity, even in small amounts, and increase to the (mostly achievable) 30 minutes per day for
5 days per week, even at moderate intensity. Other U.S. guidelines (42,43) do not specify half an hour daily,
but simply ≥150 minutes weekly, suggesting that longer sessions several days per week are sufficient. For both
middle-aged and older adults, greater benefits are conferred by ≥300 minutes per week of activity (43). Note
that all activity can be moderate-intensity, or that it can be 75 minutes per week of vigorous-intensity activity,
which will provide the same benefits; and is the approximate equivalent to 150 minutes of moderate-intensity
activity. These guidelines were generally supported by the 2011 American College of Sports Medicine
position statement, indicating that activity can be accumulated in different ways and through different types of
activity, as long as the total accumulated meets recommended levels for health and fitness (57). From the
counseling perspective, combinations of moderate and vigorous activity are permitted. For example, a client
who does 30 minutes of jogging twice a week, and walks the dog for 20 minutes on 2 other days is doing
“sufficient activity” (this is above the threshold, as it equates to around 160 “moderate minutes” (30 + 30
vigorous minutes) × 2 + (20 + 20 moderate minutes) (2).
TABLE 7.2 Key WHO and U.S. Guidelines for Physical Activity—Implications for Behavioral Counseling (52,55)
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One caveat for practitioners is the contribution of physical activity for weight loss. The behavior change
counselor should consider the concept of “active living,” especially when clients want to use physical activity to
support weight loss. In order to lose weight, substantially more than 150 minutes per week are required;
ACSM’s Guidelines for Exercise Testing and Prescription recommends participation in at least 300 minutes per
week of moderate-intensity activity (1). The ACSM Position Stand on physical activity for weight loss and
the prevention of weight gain similarly advises participation in at least 250 minutes per week of moderate-
intensity activity (38).
In addition to the guidelines in Table 7.2, all adults are encouraged to do strength training activities twice
per week. In addition, older adults are encouraged to maintain balance and muscle strength to reduce risk of
injurious falls. In summary, any activity is better than none, and the WHO guidelines make this explicit for
older adults:“When adults cannot do the recommended amounts of physical activity due to health conditions, they
should be as physically active as their abilities and conditions allow” (12). This concept is relevant to clinical
counseling, as the first behavior change goal is to activate those who are completely sedentary, and encourage
them to try, adopt, and maintain at least some regular physical activity.
Policy as Unwritten Social Norms
The third definition of policy encompasses unwritten social norms that influence human behavior. It is
apparent that physical activity has strong societal determinants, including the sedentary and pervasive
automobile and television cultures in many countries (46). Social influences are strong cues to inactive
behaviors. These may be direct peer influences, especially in adolescence. This is a definition of “policy”
beyond the scope of this chapter, but it remains important to consider the social context of any client as a cue
to inactive choices and role modeling, within their family, peers, and colleagues.
The Physical Environment and Physical Activity

The links between policy and the physical environment are shown in the center and right side of Figure 7.1.
Planning processes will lead to policy, which in turn will influence environments to become activity-friendly.
The physical environment is important in supporting the adoption and maintenance of active lifestyles among
adults and children (54). Recently, the concept of “active living” has emerged to expand the concept of
“physical activity” by emphasizing the different domains of physical activity including leisure-time, active
travel, household, and work-related activities (37). This has led to the use of socio-ecological models, which
emphasize the importance of environmental influences on physical activity (19,39,48).
The built environment encompasses land use patterns, the transportation system, and design features that
can all affect physical activity levels (4). At the level of the building, the accessibility of stairwells and other
design issues may be relevant to encouraging physical activity (15). Moreover, the provision of showers and
storage for bicycles in worksites could facilitate active commuting to work (53).
At the neighborhood level, the provision of sidewalks and cycling paths; access to shops, parks and open
space, exercise facilities, and other places of interest; high aesthetics; adequate street lighting; and mixed land
use can all contribute to an active lifestyle. On the other hand, sprawl, low street connectivity, and heavy
traffic might impede physical activity (16).
At the regional level, the physical environment includes consideration of the distances between where
people live and the places where they work, shop, or attend school. Longer distances will make active
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transport options (traveling to or from work or shops by walking, cycling, or using public transport) more
difficult, unless there is a well-connected public transportation system. Even walking to and from public
transport stops can contribute to achieving the recommended level of physical activity, particularly among
those population groups that are at highest risk of being insufficiently active (10,32).
Evidence Summary
The past two decades have produced hundreds of studies documenting the relationship between the built
environment and physical activity. Various literature reviews have synthesized this emerging evidence
(11,21,23).
To date, the vast majority of studies have had a cross-sectional research design, and therefore do not
provide causal evidence, which is a limitation of the literature (23,34). These studies mostly showed that
physical activity was associated with residential density, mixed land use, street connectivity, parks, footpaths,
trails, and walkable destinations, such as shops and recreation facilities. The associations for aesthetics and
safety from crime and traffic were less consistent (8,28,35,45). In addition, a few relocation studies have
examined the influence of an exposure to neighborhoods with different walkability on levels of physical
activity (24,25,41). One study (5) found that moving to a more walkable neighborhood was associated with an
increase in physical activity. The few studies that have changed or enhanced the environment have shown
mixed evidence of effectiveness on physical activity levels (17,29,33,44,51,55,56). Nonetheless, the net sum of
this research suggests important links between the environment and whether people are physically active or
not.
STEP-BY-STEP
Step 1. Making Sense of Policy from a Practice Perspective

There are several links between policy and physical activity practice.
First, you can become advocates for physical activity in your communities by advocating to your local
hospital, health department, municipality or other agency to increase the profile of, and facilities for, physical
activity in your community (26). This is an important role for practitioners in supporting and developing
community-based integrated programs that encourage people to be more active. This first step in physical
activity advocacy is to persuade the community and local decision makers to invest in the program (49).
Policies to promote physical activity may utilize behavior change theories and models that are discussed
elsewhere in this book (see Chapter 1 and 4). Health behavior change theory can help decision makers decide
if a policy is likely to be effective (47). For example, communication policies to inform populations about
becoming more active may have theoretically developed messages (e.g., Theory of reasoned action) (14), or
may use diffusion of innovations approaches to reach many people (7). This approach suggests that once a
target behavior becomes widely accepted as easy to do, affordable, accessible, and convenient for a population,
they will start to change in large numbers, in this case becoming more physically active. Policies that
encourage healthy environments may use a socio-ecologic model (34,39), encouraging both the individual
change approach provided through counseling and programs, in concert with an improved environment to
facilitate active living. Considerable research has shown that both individual and environmental factors, taken
together, explain physical activity behavior better than either approach alone (31). This is illustrated in Figure
7.1, where both individual and environmental change together make “active choices the easy choices.” These
data suggest a link between individual approaches and-facilitatory environments is synergistic. For example, it
is not much use encouraging people to walk if their house is surrounded by freeways, there is limited public
transportation, and the environment is unsafe. Consideration of these issues may suggest that this person
needs to get most of their physical activity in a structured exercise program—for example, at a local YMCA or
similar.
Other policy initiatives may also add to individual programs. For example, a policy that offers incentives for
public transport, active commuting, decreased health costs, or a group competition to accumulate the most
steps in a worksite—all of these can be linked to individual advice. Policies that offer “point of choice decision
prompts” to be active—for example, through promoting stair use instead of elevator use—may also help to
accumulate small increments of activity across the day (15). Cost-effectiveness analysts suggest this kind of
low-cost, high-reach environmental intervention may be very inexpensive, in terms of costs per unit of energy
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expended (12).
One new dimension of policy relates to those that reduce sitting and sedentary time. It may be that
prolonged sitting contributes more to total daily energy expenditure than physical activity time, and hence to
the development of obesity (6). Strategies to reduce sitting will probably form part of the policy portfolios of
the future, once the epidemiological threshold for risks associated with sitting are identified (52).
Step 2. Using the Physical Environment to Promote Physical Activity

“Active living” need not be difficult or expensive, and should become part of any physical activity regimen. It
is simple to integrate physical activities into daily routines, at work, at home, in leisure time, and through the
choices we make around transport. Examples of active living are shown in Table 7.3. In terms of physical
activity counseling, this is a key component of nonstructured physical activity that one could recommend to
inactive adults. In addition to attending any structured exercise programs, and especially for those that are
unable or unwilling to participate in programs, the active living environment becomes a vital setting for their
physical activity. (See also Case Scenarios 7.1 through 7.4 later in this chapter.)
TABLE 7.3 Elements that Contribute to Active Living
Element Examples
Walkability and connectivity Improve safe and easy active travel connections to local destinations.
Active travel alternatives Efficient public transport use, well signposted biking and walking routes and facilities to reduce car
dependency and use; safe routes to school for children.
Quality public space, minimal Maintain high-quality and safe parks, trails, open space for the community to use.
incivilities
Social interaction and inclusion Promote mixed use retail districts that encourage walking and cycling for local trips.
Perceived and objectively safe Well-lit sidewalks, even and well-maintained surfaces (for the elderly, to reduce falls risk)
environments
Domestic environments can be Doing gardening, household chores, and using these as “energy expenditure opportunities” as well as
made to be more active tasks
One component of the environment relevant to behavior change is the concept of “walkability.”
Neighborhood walkability measures how conducive a neighborhood is to walking. A high “walkable”
neighborhood contains high residential density, well-connected streets, and mixed land use (workplaces,
shops, and facilities, as well as residential dwellings) and is associated with lower body mass index (BMI) and
higher physical activity levels (20). Health and fitness practitioners should become aware of the walkability
scores in common use, and encourage clients to be active in more walkable local areas. Examples of tools to
measure walkability are found in From the Practical Toolbox 7.1. When the walkability of the client’s area has
been established, the practitioner can then prescribe a program of physical activity which can incorporate the
principles of active living. For example, walking to local destinations or in local parks can be specifically
integrated into the client’s regular routine and activities.
CLINICAL COUNSELING AND COMMUNITY PRACTICE VIGNETTES
Case Scenarios 7.1 through 7.4 are designed to illustrate the kinds of specific roles that practitioners and
behavioral scientists could play in promoting physical activity through the built environment. The first
involves a practitioner advising a client to better understand their environment and its physical activity
opportunities, and to use a pedometer to track their steps each day as a form of behavioral self-monitoring
(35). The second scenario focuses on encouraging “active living”, building physical activity into everyday life.
The third scenario illustrates a public health approach, where a committed practitioner in a small-midsized
community might work with other agencies to build better infrastructure to encourage the population to be
more active (49). The fourth scenario is an example of a “point-of-choice decision prompting” intervention—
for example, to encourage stair use rather than elevator use—that is evidence-based, and now should be
developed in practice in many settings such as in workplaces, malls, and train stations.
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EXAMPLES OF WALKABILITY CHECKLISTS/RESOURCES (12,13,53)

Partnership for a Walkable America Walkability Checklist encourages people to rate an area for walking
and identify what can be done to improve the walking score in both the short-term and long-term.
This is useful in planning local community walking groups.
Available from http://www.walkableamerica.org/.
Heart Foundation (Australia) Neighbourhood Walkability Checklist is designed to help individuals and
groups survey their local walking environment. As well as a checklist, it has a template to use in
writing to local municipalities about improving walkability.
Available from http://www.heartfoundation.org.au/SiteCollectionDocuments/
HFW-Walkability-Checklist.pdf or with a tiny URL: http://tinyurl.com/3uwcmtb.
Walk Score is an international tool that measures the walkability of any address, providing a score
from 0 (car-dependent) to 100 (walker’s paradise). The measure is based on the presence of local
destinations, but does not include availability and quality of footpaths or public transport
infrastructure (12,13).
Available from http://www.walkscore.com.
www.ratemystreet.co.uk allows users to rate streets on a five-star system using eight criteria: Crossing
the street; pavement (sidewalk) width; trip hazards; finding your way; safety from crime; safety from
traffic; clean/attractive; disabled access. This is a British program.
Case Scenario 7.1
Belinda is a certified Health Fitness Specialist and uses motivational interviewing techniques to advise
clients on how to be more physically active, using behavior change theories when appropriate. Brian is
one of Belinda’s clients, and he works long hours and often travels long distances on work trips and feels
he has little time for physical activity.
Belinda advises Brian to conduct an audit of his local neighborhood for walkability, although he is
new to the area and is still unfamiliar with his local surroundings. Belinda helps Brian identify
destinations of interest in his local neighborhood and encourages him to have his bicycle serviced so he
can travel to local places such as the hardware store. Brian owns a dog, which his wife normally walks,
and Belinda suggests he and his wife exercise the dog together in the evenings. Belinda gives Brian a
pedometer to help track his progress toward increasing his daily walking by at least 2000 to 3000 more
steps.
Case Scenario 7.2
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Blend Images/Shutterstock.com
Victoria would like to be more physically active and prefers exercising outside in her local neighborhood.
Through her health insurance, she makes an appointment to see a wellovness consultant, John.
John identifies Victoria’s local residential neighborhood has low walk-ability. However, the
neighborhood where her office is located has a higher walkability. John develops a physical activity
program for Victoria that includes taking regular lunchtime walks of at least 15 minutes to increase her
physical activity and reduce time spent sitting in the workplace. The program also includes opportunities
to participate in outdoor activities on weekends and in evenings in the summer, such as cycling.
John also encourages Victoria to help improve her community’s walkability score by using some of the
suggestions in the Partnership for a Walkable America Walkability checklist (see From the Practical
Toolbox 7.1), such as exploring alternative walking routes and reporting unsafe conditions like broken
sidewalks to her local authority.
Case Scenario 7.3
Working with a small to mid-sized local community, an exercise or prevention practitioner has
discussions with a range of people interested in promoting physical activity in this municipality or
county. These include the local Planning Department, the Mayor’s office, the bus company (active
transport), the Engineering department (for building trails and infrastructure), and the Hospital Health
Education unit. Identifying common needs, the practitioner convenes an initial planning meeting,
which may lead to the development of a community taskforce to address physical activity opportunities
from a range of agencies and different sector perspectives. Over 12 to 24 months, the taskforce meetings
result in an increase in built infrastructure (such as rail trails or park redevelopments), improved mayoral
popularity, and increased population participation in health-enhancing physical activity across the
community.
Case Scenario 7.4
AVAVA/Shutterstock.com
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This is a generic scenario for behavior change that could be applied in thousands of offices, multi-story
shopping malls, train stations, and other settings. The intervention is point-of-choice signage to
encourage people in that environment to use the stairs rather than the elevator or escalator. Each day,
millions make the “inactive choice” of using the elevator or escalator, and a simple sign to ‘use the stairs
for health” can encourage people to make the cognitive decision to change to an active mode of moving
from one floor to the next.
Intervention studies have documented the efficacy of these interventions in colleges and health
centers, but many community settings could benefit. The challenge in practice is to implement these
cheap, feasible stair-use motivational signs in buildings, shops, and other facilities to encourage active
stair use. This incidental physical activity intervention implemented across the whole population would
be of substantial benefit.
TAKE-HOME MESSAGES
Making the links between policy, environments, and individual counseling is not initially obvious. In
this area of work, the underlying summary goal for practitioners is to work out how to build physical
activity into more of your clients’ everyday lives. To do this, you need to know more about your clients’
local environments, and opportunities for activity, and help them to make choices about where and
what kinds of incidental activity might be suitable for them so as to add to possible structured programs
that they might participate in. For many of them, attending structured programs may be difficult or not
well maintained in the long term, so to realize optimal health-building physical activity into everyday
lifestyles becomes the central behavioral goal.
In summary, policies can support active living opportunities at local or city-wide levels, and physical
activity professionals need to contribute here to making their urban environments more physical
activity–friendly. Becoming an “advocate” for physical activity is a personal and professional goal, but if
enough advocates pressure policy makers at local and national levels, it does contribute to building the
supports for population physical activity participation. This kind of advocacy is becoming a public
health part of behavior change practice. This has led to the launch of the American National Physical
Activity Plan (53), a multistrategy policy initiative to get Americans to become more active. Finally, the
release and update of physical activity guidelines allows updated messages for practitioners to
understand, define, and explain the amount, intensity, and frequency of activity for health that their
clients need.
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In the preceding chapters, you have learned about behavior change from theory to practice, including how to
use the many valuable tools and strategies for the successful promotion of physical activity interventions. In
this chapter, we discuss the evidence for intervening within targeted groups—children, the elderly, and within
chronic disease populations—and provide the tools and resources to tailor the intervention to those you are
working with.
Physical activity (PA) has been well documented as an important contributor to overall health and well-
being (20,39). However, the latest numbers in the United States suggest that only 48.8% of the
population is currently meeting physical activity recommendations of at least 150 minutes of moderate-
to vigorous-intensity activity distributed over 3 to 5 days per week (1,7). Moderate-intensity activity is
defined as activity producing small increases in breathing and heart rate, and these recommendations of
at least 150 minutes of moderate-intensity activity per week are associated with improved overall health
outcomes (43). With over one third of the population reporting insufficient levels of activity (37.7%),
and 13.5% of the population remaining completely inactive, a total of 51.2% of people in the U.S. are
not participating in enough activity to receive the associated health benefits (7). This issue of inactivity
becomes even more important when we consider populations that have potentially “more to gain” from
being active—or “more to lose” from an inactive lifestyle. Such populations include, but are not limited
to, children, the elderly, and those with various medical conditions.
The specific population is essentially the first level of “tailoring” for effective intervening, allowing for
the values, traditions, and cultural and demographic norms to be reflected in PA promotion (48).
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Effective PA promotion at the population level further necessitates tailoring of more specific variables,
including the needs of the particular group or individual within the given population, the training of the
given fitness instructor or coach, and the content of the PA intervention, including the psychosocial and
behavioral components. Consideration of the population is particularly important since varying
populations experience different perceptions of, and barriers to, PA (48,26). Given that PA adoption
and adherence are so poor in the general population and may be even more pronounced in specific
populations, the tailoring of the PA prescription within the intervention needs to specifically examine
determinants of, and barriers to, PA, including physiological, psychosocial, and environmental factors
(19). Current research strongly advocates for the translation of evidence on the benefits of PA into
optimal models of behavior change in which determinants of PA, including exercise preferences and
barriers, are incorporated into interventions (11). See also From the Practical Toolbox 8.1.
As a professional in the exercise and fitness industry, it is important to recognize the principles of PA
promotion and behavior change and how to apply these principles to different populations and
individuals (see Chapters 1 to 5). In each section, we will provide population-specific tips to help
improve activity adoption and maintenance. These suggested techniques can help you promote
improved client confidence and self-efficacy (the belief that your client can accomplish the exercise goals
he or she has set), and improve the likelihood that your client will adhere to and maintain the exercise
recommendations that you provide. As discussed in Chapter 3, we will consider personal factors,
behavioral factors, environmental factors, and program-related factors.
The following sections consider the rationale and evidence for intervening with the following
populations:
1. Children and youth
2. The elderly
3. Chronic medical conditions, including a spotlight on PA interventions for cancer survivors
CHILDREN AND YOUTH
The Evidence
In children, recent numbers indicate very high levels of inactivity, despite the recommended 60 minutes or
more of PA each day (see Table 8.1 for recommendations) (7). The U.S. Youth Risk Behavior Surveillance
conducted in 2009 showed that among high school students (grade 9–12), only 17.3%–19.5% reported
participating in PA for at least 60 minutes 7 days a week, and only 35.2%–38.8% reported participating in PA
for at least 60 minutes 5 days a week (6). Between 21.5%–24.8% of high school students reported not
participating in at least 60 minutes of PA on any day of the week (6).
PA participation among children and youth has been linked to health benefits associated with development,
mental abilities, school behavior, and academic achievement (42). Concern with childhood inactivity is on the
rise, and the prevalence of overweight children is increasing rapidly (7,12,40). This associated increase in
overweight and other chronic conditions including obesity, heart disease, and musculoskeletal conditions, is
now reported at younger ages and is linked to diminished quality of life, premature illness and death, and
increased health care costs as these children age (12,32). Since PA levels in children are a strong predictor of
PA levels into adulthood, developing successful interventions for children is a necessity to improve health
outcomes as well as increase lifelong PA participation (41).
Recommendations
Children between the ages of 6 and 17 should be getting at least 60 minutes of physical activity each day (7).
See Table 8.1.
Step-by-Step
See Table 8.2 for step-by-step instructions on implementing PA interventions for children and youth, and
Table 8.3 for a summary of successful interventions in this population.
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EXPLORE EXERCISE PREFERENCES

One of the most important predictors of long-term PA adherence is whether or not the exercise
program is specifically designed to meet the client’s goals, personal preferences, and lifestyle and
environmental factors. It is important to first evaluate your client’s lifestyle, and exercise preferences
before creating a PA program. It is also important to evaluate current barriers to exercises and
personal characteristics that will motivate the client to adopt an active lifestyle.
The Healthy Physical Activity Participation Questionnaire

This questionnaire evaluates frequency, intensity, and perceived fitness and gives a total “heath
benefit” score.
http://www.getactivepenticton.com/gap/assets/thehealthyphysicalactivityparticipationquestionnaire.pdf
The Fantastic Lifestyle Checklist

This is a simple checklist which provides clients with a “health benefit” rating based on various
lifestyle habits.
http://hk.humankinetics.com/AdvancedFitnessAssessmentandExercisePrescription/IG/App_A5.pdf
TABLE 8.1 PA Recommendations for Children and Youth (1,7,43)
Activity Type Recommended Weekly Frequency, Intensity, and Time Examples
Aerobic Moderate Intensity Activity should make up the majority of the • Activities like brisk walking, cycling, hiking,
recommended minimum 60 minutes per day. rollerblading, skateboarding.
• Games like baseball and golf
Vigorous Intensity Activity: Include at least 3 days per week. • Activities that include running, cycling, jumping,
dancing, skiing
• Games like hockey, basketball, swimming, soccer
Strength At least 3 days per week as a part of the minimum 60 minutes • Activities that include pulling or pushing,
Training per day. supporting bodyweight
• Games like tree climbing, swinging on
playground equipment, or playing tug-of-war
• Resistance exercises using body weight or
resistance bands may be performed
Bone At least 3 days per week as a part of the minimum 60 minutes • Activities that include hopping, skipping, and
Strengthening per day. jumping
• Games like jump rope, and hopscotch
• Running
Source: Physical Activity Guidelines for Americans, U.S. Department of Health and Human Services, 2008; Physical Activity for Everyone, CDC,
2011; American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott
TABLE 8.2 Implementing PA Programs for Children and Youth (1)
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TABLE 8.3 Successful Interventions and Strategies: PA Interventions for Children and Youth
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PHYSICAL ACTIVITY CALENDAR

Planning and scheduling PA is a great way to increase PA participation. Using a calendar to plan
activities for the next month is a simple yet effective way to start recording activity. See the following
calendar for an example.
Let’s Move! Healthy Family Calendar
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FITNESS TESTING
Fitness testing must be adapted to suit the population and individual you are working with.
ACSM’s Guidelines for Exercise Testing and Prescription

This resource offers a clear and specific approach to exercise testing. More fitness testing resources
can be found at http://www.acsm.org/.
Rated Perceived Exertion Scale

Before beginning fitness testing, it is important to teach clients about the Rated Perceived Exertion
Scale so they are able to clearly communicate their level of exercise intensity throughout testing and
future physical activity participation. The Borg Rated Perceived Exertion Scale can be found at
http://www.cdc.gov/physicalactivity/everyone/measuring/exertion.html.
Barriers
Current barriers to PA participation include lack of time due to other obligations, lack of interest or
motivation, body-related barriers (e.g., body self-consciousness), social barriers, and environmental barriers
(e.g., no equipment, unsuitable weather) (49).
Adherence and Maintenance Considerations

Improving parental, school, and community support, and providing access to environments that promote PA,
are helpful at improving adherence. Table 8.4 highlights important PA adherence and maintenance
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techniques for children and youth. Enhancing children’s knowledge of PA benefits, improving motivation and
time management skills, and offering a variety of exercise opportunities are all useful strategies (30). Further
strategies to overcome these barriers are important and research into effective interventions is ongoing (see
Table 8.3).
TABLE 8.4 Techniques to Improve Children’s PA Adherence and Maintenance
Factor Techniques for Adherence/Maintenance
Personal • Always consider PA history, personal abilities, preferences, and personal resources.
Behavioral • Encourage children to set realistic and achievable PA goals.

• Plan for rewards once activity goals are reached.
• Ensure PA is used as a reward, and not as a punishment (i.e., going for a family walk vs. having to run laps for
punishment).
• Encourage children to practice self-monitoring techniques (i.e., journaling).
Environmental • Promote activity that is safe, accessible, and affordable.
Program • Encourage children to try different types of activities to prevent boredom and improve overall fitness skills.
ADHERING TO EXERCISE: PHYSICAL ACTIVITY JOURNAL

While interventions, when well-designed, can clearly provide numerous positive physical and
psychosocial benefits to the target population, our greater concern is the “next step.” Specifically,
what must be done to ensure that individuals maintain activity after the completion of a formal PA
intervention?
A journal can help to evaluate the frequency of exercise, intensity, duration, and type of activity.
Journals can be “paper and pencil” or can be kept electronically on one of the many online lifestyle
recording Web sites.
• A sample journal and tracking log can be found in From the Practical Toolbox 3.6.
• An example of an online tracking Web site is: http://www.mypyramidtracker.gov/.
• Check out the Center for Disease Control’s online PA tracking tool:
http://www.bam.gov/sub_physicalactivity/physicalactivity_activitycalendar.html.
For more on setting and maintaining exercise goals, refer to Chapters 2 and 3.
Useful Links
Refer to the following Web sites on this topic for more information:
• Active Healthy Kids Canada: http://www.activehealthykids.ca/
• American Academy of Pediatrics: http://www.healthychildren.org/English/healthy-
living/Pages/default.aspx
• Center for Disease Control and Prevention: Physical Activity for Everyone:
http://www.cdc.gov/physicalactivity/everyone/guidelines/children.html
Case Scenario 8.1
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v.s.anandhakrishna/Shutterstock.com
Name: Steven Johnston

Age: 15
Presentation: Steven and his mom visit a local fitness center in search of an exercise program that will
help Steven feel more comfortable participating in physical education class at school. His mom is
worried because Steven’s teacher reports very poor participation and lack of attendance in class. Steven
says that if he could keep up with the other children in class, he would be more likely to actively
participate.
TAKE-HOME MESSAGE
Both the physical and psychological health benefits of PA for children and youth are well documented,
but with activity participation levels remaining low, improving ways to effectively promote PA is crucial
(40,42). Decreasing perceived barriers to PA participation and improving PA accessibility is our
responsibility as parents, teachers, coaches, personal trainers, and policy makers. As indicated earlier in
Table 8.3, successful interventions focus on increasing PA participation minutes during regularly
scheduled physical education class (the SPARK campaign) (35), utilizing marketing techniques so as to
brand PA as “cool” and “fun” (the VERB campaign), and promoting lifestyle PA adoption (PLAY
campaign) (31). Utilizing these tools to help improve children and youth’s perception of PA,
accessibility to sport and active playtime, and to effectively adopt active lifestyles will provide
meaningful benefits to children and effectively encourage lifelong PA participation.
OLDER ADULTS
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The Evidence
The 150 weekly minutes of moderate-intensity activity for older adults (65 years plus) is not currently met by
over 60% of older adults in the U.S. (1,7) (see Table 8.5 for complete recommendations). While there is a
decline in activity as a natural part of aging, the literature clearly supports that promotion of activity can be
successful in older adults and lessen many of the negative side-effects associated with aging, including
decreased health and functional independence (24). Participation in regular PA also improves cardiovascular
function in older adults, reduces risk factors associated with disease states, improves body composition and
bone health, improves quality of life and cognition, and extends life expectancy (10). Table 8.6 outlines key
steps necessary to the implementation of a successful PA program for older adults.
A second reason for promoting PA interventions in older adults comes from the increase in our aging
population. Older adults are the least physically active of any age group and yet are the most rapidly growing
age group, with this population expected to double by 2030 (13). Creating mass interventions that promote
moderate-intensity aerobic activity, muscular strengthening, flexibility, balance, and risk management is
meaningful for a large portion of this population.
Recommendations
Adults aged 65 years and older are recommended to participate in 150–300 minutes of moderate-intensity
activity every week (1). Alternatively, older adults can accumulate 75–100 minutes of vigorous intensity
activity every week (1). In addition to this aerobic exercise, 2 or more days of muscle strengthening activities
are recommended. (See Table 8.5.)
Step-by-Step
See Table 8.6 for steps for implementing physical activity programs for older adults, and Table 8.7 references
effective interventions and practical, evidence-based behavior change strategies.
Barriers
Barriers to PA participation among older adults may include, but are not restricted to, a past inactive lifestyle
and decreased understanding of PA benefits, physical frailty and/or health issues that may restrict mobility,
fear of injury or falling, lack of guidance, and the cost of transport or access to exercise facilities (5,9).
Furthermore, if older adults are residing in long-term care facilities, they may face increased barriers to PA,
including limited access to exercise space or equipment (9).

Strategies to increase PA options for the elderly can be seen in Table 8.8.
TABLE 8.5 PA Recommendations for Older Adults (1,3,10)
Activity Recommended Weekly Frequency, Intensity, Type Examples

Type and Time
Aerobic Moderate Intensity Activity: at least 5 days per • Activities like walking, golf, cycling, gardening, house cleaning
week for 30–60 minutes per day, totaling 150–
300 minutes per week.
Vigorous Intensity Activity: for at least 3 days • Activities that include jogging, dancing, aerobics or water aerobics,
per week for at least 20 to 30 minutes per day, swimming, cycling
totaling 75–100 minutes per week. • Games like tennis
Strength At least 2 days per week at moderate intensity • Activities that include pulling or pushing, supporting bodyweight
Training (60%–70% 1RM) or low intensity (40%–50% • Exercises using hand weights, weight machines, resistance bands
1RM) for older adults beginning a resistance
• Resistance exercises using body weight or calisthenics-type exercises
training program.
• Activities of daily living including carrying groceries, getting up and
down from a chair or the floor
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Balance At least 3 days per week as a part of the • Exercises that progressively reduce the base of support, dynamic
Exercises minimum 60 minutes per day. movements that challenge the center of gravity, exercises that stress
postural muscles, or exercises that reduce sensory input (i.e., stand or
balance with eyes closed)
• Balance on one leg, balance on toes or heels
• Activities such as walking backward or in circles
• Activities such as yoga or tai chi
Flexibility At least 2 days per week • Performing static stretches from a prone, seated, or standing position
• Holding stretches for at least 30–60 seconds and maintaining stretch
below point of discomfort
Source: American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott
Williams and Wilkins; 2014; ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, 3rd edition, 2009 (3);
Chodzko-Zajko et al., 2009 (10).
TABLE 8.6 Implementing PA Programs for Older Adults (7)
TABLE 8.7 Successful Interventions and Strategies: PA Interventions for Older Adults
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TABLE 8.8 Techniques to Improve Older Adults’ PA Adherence and Maintenance
Personal • Always consider PA history, personal abilities, medical conditions, preferences, and personal resources.
• The older adult should feel safe and well monitored during exercise.
Behavioral • Encourage older adults to set realistic and achievable PA goals.

• Encourage older adults to practice self-monitoring techniques (i.e., journaling, keeping a calendar).
Environmental • Promote activity that is safe, accessible, and affordable.

• Encourage group-based activities since the social aspect may improve accountability and enjoyment.
Program • Encourage older adults to try different types of activities to prevent boredom and improve overall fitness.
Useful Links
• Active Aging Partnership: http://www.agingblueprint.org/partnership.cfm
• Center for Disease Control and Prevention: Physical Activity for Everyone:
http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html
• Elder Gym: http://www.eldergym.com/exercises.html
• Elderly Activities: http://www.elderlyactivities.co.uk/
• Senior Exercise and Fitness Tips: http://www.helpguide.org/life/senior_fitness_sports.htm
Case Scenario 8.2
Jan Mika//Shutterstock.com
Name: Ellie Jones
189
Age: 72
Presentation: Ellie is a 72-year-old widower, living independently. She enjoys social activities with
friends, but currently does not participate in any regular physical activity. Her doctor has recommended
beginning an exercise program, in part to deal with her osteoporosis and weight gain issues. However,
Ellie does not know where to begin!
TAKE-HOME MESSAGE
Older adults have much to gain from participating in regular PA, including maintaining current
physical functioning, managing current chronic disease and preventing further medical conditions, and
enhancing quality of life (29). Unfortunately, older adults are at a high risk for living sedentary lifestyles
(24). Significant predictors of long-term adherence to active lifestyles in older adults include more
positive affect and higher self-efficacy (27). Overall, interventions designed to promote PA among older
adults have been promising, confirming many health benefits for participants who engage in an active
lifestyle long term (24).
Increased health concerns in an aging population make the necessity of intervening with older adults
a priority. Initiatives must consider how to make active living part of the natural aging process.
Consideration of personal barriers including health and mobility, motivation, as well as social support
and environmental barriers such as accessibility to safe exercise environments is essential.
OVERVIEW OF COMMON CHRONIC CONDITIONS
Numerous chronic diseases may be managed effectively with PA interventions. While it is outside the scope of
the current chapter to provide details on PA interventions for all conditions, this section of the chapter
provides a brief overview of chronic conditions that have substantial evidence for the role of PA in disease
management. In addition, with recent advancements in our understanding of the benefits of PA for cancer
survivors, we chose to highlight this condition in greater depth.
With all chronic conditions, it is extremely important to engage the appropriate health care professionals to
ensure the safety and appropriateness of the intervention for the particular population. Simple screening tools,
such as the Par-MEDX (see Chapter 2) should be employed to ensure physician clearance prior to the start of
the PA program. Additional tools for screening, evaluation, and feedback should be utilized as specific to the
chronic conditions as possible. See the From the Practical Toolbox features in this chapter and other chapters
of this book for examples of these resources.
Behavioral strategies to promote PA adoption, adherence, and maintenance are extremely important for
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people with chronic conditions. These individuals may be apprehensive about starting a new PA program or
addressing activity levels following changes in health status. These issues highlight the need for tailored PA
interventions that include effective behavior change strategies.

Table 8.9 highlights key behavior change strategies when working with people with varying chronic
conditions. These strategies can be further tailored to the individual’s condition and tailored based on health
history, need, interests, and preferences.
COMMON CHRONIC CONDITIONS
Overweight and Obesity

Worldwide obesity rates are reported to be at epidemic proportions, with over 1.5 billion adults considered
overweight, and of these, 500 million considered obese (47). Obesity is linked to a multitude of lifelong
physical and psychological health complications, yet PA holds significant value in terms of an effective
treatment option in helping to burn calories and manage energy imbalances (18). PA also plays a key role in
psychological well-being, cardiovascular fitness, and maintaining weight loss (18). See Table 8.10 for
recommendations and considerations for overweight and obese individuals and populations.
TABLE 8.9 Techniques to Improve PA Adherence and Maintenance
Personal • Consider PA history, personal abilities, other medical conditions, preferences, and personal resources.
• The person should feel safe and be well monitored during exercise.
• The medical team should be aware and grant permission for the person to participate in activity and promote exercise
adherence and maintenance. This can be promoted through personal fitness reports generated by the fitness
professional for the medical team.
Behavioral • Encourage people to set realistic and achievable PA goals.

• Remind people currently being treated for their condition to adjust total activity minutes and intensity based on
treatment side-effects.
• Encourage people to practice self-monitoring techniques (i.e., journaling, keeping a calendar).
Environmental • Promote activity that is safe, accessible, affordable, and lead by exercise practitioners with specific experience in the
necessary field.
• Encourage group-based activities as the social aspect may improve accountability, enjoyment, and support.
Program • Disease-specific programs may provide increased peace of mind for individuals.
• People can start slowly in activities like yoga, and increase total activity minutes and intensity from there.
Cardiovascular Disease
Cardiovascular disease remains the leading cause of death and disability among adult men and women in the
United States, and physical inactivity is well defined as an independent risk factor for this disease (8,44). The
benefits of PA extend beyond prevention and management of heart disease, aiding weight management, the
prevention of further disability, and reducing depression and anxiety—all of which are closely associated with
cardiovascular disease (46,50). See Table 8.11 for recommendations and considerations for individuals and
populations with cardiovascular disease.
Cancer: The Role of Physical Activity for Cancer Survivors
EVIDENCE
The rapidly accumulating research clearly indicates a beneficial role of PA for cancer survivors, both during
191
and after treatment (21,36,37). PA improves a variety of physical, psychosocial, and health outcomes in cancer
survivors, both during and after cancer treatment, including the management of the potential negative long-
term effects of treatment (25,38). Research indicates that the sooner cancer survivors reestablish or improve
upon prediagnosis PA levels, the more likely they are to report both physical and psychosocial benefits. These
individuals may also exhibit fewer symptoms, less comorbidities, and decreased all-cause mortality (17,23).
TABLE 8.10 PA Recommendations and Considerations for Overweight and Obese Individuals and Populations
(1,7,14)
Recommendations • Exercising at least 5 days per week

• At least 150 minutes per week progressing to at least 300 minutes per week of moderate-intensity activity, or 150
minutes of vigorous-intensity activity per week.
• Intensity: Moderate to vigorous-intensity physical activity should be encouraged.
• Focus should be on aerobic activity that utilizes large muscle groups. Resistance training at least 2 days per week
should be included.
Barriers • Feelings of insecurity and discomfort when exercising

• Tiredness
• Fear of injury
• Low self-esteem, diminished self-efficacy for being active
• Diminished self-worth and decreased perceived control
• Higher prevalence of comorbidities
Interventions • Weight loss of at least 5% to 10% of initial body weight over a three- to six-month period will provide significant
health benefits.
• For adequate weight loss, energy intake must be addressed. Patient should consult with dietitian and together with
exercise programming, a deficit of 500 to 1000 kcal / day should be achieved.
• Reference Table 8.9 for effective behavior change techniques.
Take-Home • Helping someone who struggles with excessive weight to adopt a more active lifestyle can help to significantly
Message improve physical and psychological well-being as well as decrease the risk for comorbidities (18).
• Creating a safe exercise environment for someone who may have body image issues, comorbidities, and fear of
injury is extremely important and can directly affect long-term adherence (34).
Web links • World Health Organization: http://www.who.int/dietphysicalactivity/childhood/en/

• Centers for Disease Control and Prevention: Physical Activity for a Healthy Weight:
http://www.cdc.gov/healthyweight/physical_activity/index.html
• Scope–Healthy Choices: Physical Activity: http://www.childhood-obesity-
prevention.org/live5210/resources/healthy-choices-physical-activity/
• How to Begin an Exercise Routine for Overweight People, The Livestrong Foundation:
http://www.livestrong.com/article/16350-begin-exercise-routine-overweight-people/
Source: American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott
TABLE 8.11 Recommendations and Considerations for Individuals and Populations with Cardiovascular Disease
(1,4)
Recommendations • Exercising between three to seven times per week for 20 to 60 minutes per session. Following a cardiac event, 1- to 10-minute sessions are
recommended, followed by progression in duration.
• Exercise sessions can be split up into multiple shorter sessions per day to accommodate patients with limited exercise capacity.
• Intensity between 11 and 16 on a 6 to 20 RPE scale.
• Activities that include large muscle groups with an emphasis on caloric expenditure are encouraged. These may include use of the arm ergom
cycle ergometer, elliptical, rower, or treadmill for walking.
Barriers • Lack of time to exercise

• Lack of motivation
• Poor health
• Fear of injury
Interventions • Patients should participate in a medically supervised Cardiac Rehabilitation Program to ensure safety and promote lifestyle change adherenc
• Promote independent exercise once patient reports stable or absent cardiac symptoms, appropriate physiological response to exercise, demon
knowledge and confidence with exercise principles, and demonstrates motivation to continue exercise.
• Light resistance training programs should be introduced with slow progression.
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• For return to work, implement exercise training aimed at improving necessary energy systems used for occupational tasks.
• Reference Table 8.9 for effective behavior change techniques
Take-Home • PA is a well-established factor in the prevention and management of heart disease (44).
Message • People with cardiovascular disease should be appropriately cleared for exercise and be assigned to an individualized program that is progress
nature.
• There is a very important need to promote PA among adults who may be at risk for cardiovascular disease or who may be in the early stages
disease. Beginning a progressive PA program can help to prevent the disease and manage related risk factors.
Web links • The Heart and Stroke Foundation:

http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.5264885/k.F930/Position_Statements__Physical_Activity_Heart_Disease_and_S
• The American Heart Association: http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/Physical-
Activity_UCM_001080_SubHomePage.jsp
Source: Booth, Bauman, Owen, Core, 2007 (4); American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription.
9th ed. Baltimore (MD): Lippincott Williams and Wilkins; 2014.
BARRIERS
Despite the evidence mentioned earlier, there is a notable decrease in PA across the cancer continuum (11).
This decreased PA may be associated with increased perceived barriers to participation, both similar to those
seen in the general population (e.g., lack of motivation and time, limited access) as well as health-related
barriers such as pain and stiffness from surgery, treatment-related side-effects such as fatigue and nausea, self-
consciousness related to surgery (e.g., mastectomies), and a fear of overdoing it without proper direction (45).
Offering cancer survivors an individualized exercise program in a supportive environment can alleviate many
of these potential barriers. See Table 8.9 for additional behavior change techniques.
RECOMMENDATIONS
The recent ACSM roundtable on Exercise Guidelines for Cancer Survivors concluded that exercise is both
safe and potentially beneficial during and after cancer treatments (36). Current recommendations from
ACSM can be seen in Tables 8.12 through 8.14. These guidelines should be implemented within tailored
exercise programs, based on the individual’s current health and treatment status. Table 8.15 outlines effective
interventions and evidence-based strategies for PA adoption among cancer survivors.
In addition, the research suggests that the timing of the exercise intervention is important. It is suggested
that while regular exercise may improve outcomes during treatment, it may provide greater noticeable benefits
to the survivor when performed post-treatment (11). This may be a reflection of patients’ treatment
completion and the removal of barriers (i.e., medical demands, time, and fatigue). ACSM roundtable
guidelines suggest that cancer survivors, regardless of where they are in the treatment continuum, should avoid
inactivity and that any level of PA carries with it some benefit (36). It has been further suggested that
interventions should include multiple options based on participant preferences (33).
Useful Links
• ACS Guidelines on Nutrition and Physical Activity for Cancer Prevention:
http://www.cancer.org/Healthy/EatHealthyGetActive/ACSGuidelinesonNutritionPhysicalActivityforCancerPrevention/n
guidelines-toc
• Canadian Society of Exercise Physiology: Older Adult Cancer Survivors and Exercise:
http://www.csep.ca/english/view.asp?x=724 & id=181
• The National Cancer Institute: Physical Activity and Cancer
http://www.cancer.gov/cancertopics/factsheet/prevention/physicalactivity
TABLE 8.12 ACSM Guidelines for PA Levels for Cancer Survivors: Preexercise medical assessments and exercise
testing
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TABLE 8.13 ACSM Guidelines for PA Levels for Cancer Survivors: Exercise Prescription for Cancer Survivors
TABLE 8.14 ACSM Guidelines for PA Levels for Cancer Survivors: Review of US DHHS PAG for Americans and
Alterations Needed for Cancer Survivors
194
TABLE 8.15 Successful Interventions and Strategies: PA Interventions for Cancer Survivors
Intervention Methods Practical Strategies
PA and nutrition guidelines • Overview of the literature in nutrition • ACS guidelines for nutrition and PA cancer prevention
and recommendations for and PA interventions; provides also recommended in survivorship
cancer survivors (15) recommendations • Precautions/contraindications to exercise provided
Rationale and strategies for • Provides rationale for PA interventions • Give PA counseling during treatment, by health care
promoting PA within the and approaches to promote successful providers (HCPs), and oncologists in particular.
medical system (23) adoption and maintenance of PA • Tailor exercise programs—start (during or after
treatment); group versus alone; home versus supervised;
delivery options (mail, phone, Web-based).
• Increase oncologist knowledge and discussion of PA for
cancer survivors.
• Increase insurance coverage.
• Increase number of certified fitness professionals to
counsel/exercise cancer survivors.
Case Scenario 8.3
195
Oleg Mikhaylov/Shutterstock.coma
Name: Michael Johnson

Age: 45
Presentation: Michael was diagnosed with a carcinoma on the base of his tongue 3 months ago, and
finished chemotherapy and radiation treatments 3 weeks ago. Michael reports extreme fatigue, a lack of
energy, and a total weight loss of 45 lbs. He notices large deficits in his muscular strength and
endurance and says that he even struggles to get up from a chair due to the great muscle wasting in his
legs. His pain management is improving, but he struggles with frequent dry mouth due to treatment-
related salivary gland damage. Michael wants to increase his strength and energy, but is concerned that
he will increase his fatigue with exercise and produce more stiffness in his neck.
TAKE-HOME MESSAGE
The research on PA for cancer survivors clearly indicates both physical and psychosocial benefits. The
majority of the evidence supports the role of PA for after treatment completion. However, during-
treatment programs of low to moderate intensity may be beneficial in mitigating many of the
detrimental treatment-related side-effects. Exercise practitioners are highly encouraged to work within
a multidisciplinary health care team when delivering PA interventions to cancer survivors.
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ADDITIONAL POPULATION CONSIDERATIONS—SOCIAL INFLUENCES ON
EXERCISE
Numerous social influences, from social support and the role of influential others to the role of social norms,
may impact individuals’ PA behavior, including both the initiation and maintenance of PA. At the individual
level, the role of social support on PA behavior should be considered when tailoring an intervention.
Specifically, the social support needs and preferences for an individual (e.g., working out with others or alone;
having instrumental support for getting started) should be considered. Second, consideration should be given
to the role of influential others for the targeted population. For example, peers are an important source of
significant others for children. For older adults as well as for individuals with chronic disease, health care
professionals can play an influential role in both prescribing and advocating for PA. Third, at a population
level, cultural norms are an important consideration when planning PA interventions. The cultural norm, or
what is considered acceptable behavior for a population, along with group customs and values, can greatly
impact PA participation rates. Different cultures may also require translation services, or access to
programming within a culture’s geographic environment (i.e., delivery of a PA program for Hispanic seniors
in a Spanish Cultural Center). When working with specific cultural populations, it is important to take these
values and societal norms into consideration in order to develop the most appropriate intervention. Finally,
the social environment, including the role of the PA leader and the cohesiveness within a group exercise
environment, can be important considerations when delivering population-based PA interventions. Well-
trained leaders, with expertise/certification in working with a specific population and utilizing positive and
socially supportive leadership styles, will positively impact PA adherence.
CONCLUSIONS
Every population will experience different barriers to PA participation, but it is important to remember that
many barriers are modifiable. An exercise specialist can help to tailor a PA program so it is manageable, safe,
and tolerated, and help clients create strategies to overcome perceived barriers.
Due to the well-documented benefits of PA for various populations, future interventions focused on
strategies that promote PA maintenance are required to help people adopt long-term active lifestyles,
therefore improving quality of life, decreasing disease-related risk factors, and benefiting from the associated
cost-effectiveness of a long-term physically active lifestyle (16,28).
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As you have progressed through this book, you have read about a number of key factors to be considered
when developing a program to change physical activity behavior. It’s likely that you’ve identified a
number of new strategies that you are going to put into practice with your own clients. It’s also possible
you may want to try some new things that require more resources than you currently have, that require
approval from a supervisor, or might make your work a little more time-intensive. In these cases, it is
critical to have a good evaluation to demonstrate that your changes make a big difference in your work.
This chapter is intended to help you, as you move forward, with your physical activity promotion
plans, and demonstrate the value of any changes you are intending to implement, or to simply
demonstrate the value of your current approach. You may notice that the use of the term “value of your
program” rather than a term like “effectiveness of your program.” Whether you are in business for
yourself, working for a public health organization, or delivering care in a clinic or rehabilitation center,
you will want to demonstrate your ability to be effective. However, while demonstrating the
effectiveness of a physical activity program is necessary, it is not always sufficient to ensure that a
community or clinical strategy will be adopted and sustained by the organizations or health professionals
that are interested in delivering it (2,23).
This chapter focuses on planning and evaluating your work based on the RE-AIM framework, and
will highlight program aspects (including effectiveness) that, if optimized, will greatly improve your
chances of ongoing success (22,31,38). As depicted in Figure 9.1, running a program usually involves a
number of steps beginning with determining need, planning program characteristics and targets based
199
upon that need, implementing the program, and evaluating it for success. In most cases, these steps can
be approached in a linear way when developing a new program or when activity updating an existing
program. A useful source for physical activity program planning is “Exercise is Medicine” (see
http://exerciseismedicine.org/fitpros.html). The Web site includes resources for marketing, planning
exercise programs with a client, and other materials for both clients and organizations.
FIGURE 9.1. Running a program.
FIGURE 9.2. RE-AIM and program development questions.
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The RE-AIM framework (Figure 9.2) has been developed for both research and practice
professionals who are interested in determining the public health impact of their work. It outlines that
practitioners should assess the Reach of their work, its Effectiveness, how well it can be Adopted in
other settings or by professionals with differing levels of expertise, the degree to which it can be
Implemented appropriately (and its cost), and finally, the degree to which the strategies can be
Maintained in your practice. Table 9.1 includes a definition of each of the dimensions and gives an
example of the type of information that is necessary to evaluate your physical activity program. It also
includes an example from some of our previous research that depicts how the information could be
reported.
You will notice that some of the RE-AIM dimensions, like Reach and Effectiveness, focus on the
clients who would benefit from your expertise. Other components, like Adoption and Implementation,
focus on organizational factors, while Maintenance can pertain to either the individual level (i.e., how
long the effects of an intervention last) or organizational level (i.e., how long the program or practice can
be delivered or implemented over time). Each of the RE-AIM dimensions can be used for both
planning and evaluation purposes, so this chapter was formed around planning and evaluation
information. First, issues to consider when planning and evaluating a physical activity program, practice,
or policy intervention are provided, with successful examples from the research literature. Second, you
will walk through the methods necessary to evaluate your physical activity program to determine the
degree to which your strategies are influencing the RE-AIM metrics.
TABLE 9.1 RE-AIM Definitions, Data Requirements, and Examples from Research
Dimension and Definition Data Requirements Example Study and Outcomes
REACH: The number, percent of Denominator—number of eligible Improving the Reach of Move More (2)
target audience, and representativeness people contacted for potential Goal: To increase participation in a clinic-based
of those who participate. participation physical activity program using physician
Numerator—number of eligible prompts.
people that participate Denominator—11 patient referrals/week
Comparative information on target
Numerator—8 patients agreed to
population
participate/week
Participation Rate—72%
Representativeness—Based on census data of the
clinical catchment area, the participants were
older and more likely to be women.
EFFECTIVENESS: Change in Before and after assessments of Family Connections to Reduce Childhood
primary outcome; impact on quality of primary outcome (PO), quality of Obesity (23,46)
life; any adverse outcomes life (QOL), and potential negative Goal: To reduce weight status of obese children
outcomes (PNO) by providing parents with automated telephone
counseling that promoted changes to the home
environment.
PO: Significant reductions in BMI z-score.
QOL: Improvement in quality of life with lower
weight status.
PNO: No evidence of heightened eating
disordered symptoms
ADOPTION: Number, percent, and Denominator—number of eligible Walk Kansas (19,20)

representativeness of settings and sites/practitioners Goal: To increase physical activity through a
practitioners who participate Numerator—number of eligible group-based physical activity program delivered
sites/practitioners that participate at the county level.
Comparative information on target Denominator—105 counties in Kansas
population of sites/practitioners
Numerator—48 counties delivered the program
Participation rate—46%
Representativeness—smaller population
counties, more likely to deliver. Health educators
who personally participate in physical activity
more likely to deliver.
IMPLEMENTATION: Extent to Information on program Fit Extension

which a program or policy is delivered components and essential elements Goal: To increase physical activity in a
consistently, and the time and costs of Information on resource use community.
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the program 100% of program components were delivered as
intended
Approximately 2.5 hours of health educator time
per participant over 8 weeks.
MAINTENANCE: Long-term Primary outcome assessment 6 Family Connections demonstrated decreased

effects on primary outcome months postintervention BMI z-scores that were sustained 6 months after
Program sustainability at the Documented sustained delivery the intervention was completed
organizational level. Walk Kansas documented that the percent of
counties that maintained delivery of program up
to 5 years postresearch studies was well over
90%.
EVIDENCE
The RE-AIM framework is relatively new from a scientific perspective, introduced by Dr. Russell Glasgow
and his colleagues in 1999 (31). Introductory work included a number of systematic reviews of the scientific
literature to determine the degree to which researchers were providing information across the RE-AIM
dimensions. Over the past 12 years, the reviews have remained consistent (14,21,30,51): Researchers are good
at reporting the degree to which behavioral interventions are efficacious (i.e., the degree to which an
intervention works under optimal conditions), but don’t do a very good job reporting information such as the
representativeness of participants, characteristics and training of those delivering the interventions, time and
financial costs, or the setting in which the intervention took place. Physical activity research was included in a
number of these reviews and the findings were confirmed in a recent review of literature examining theory-
based physical activity interventions (3). Essentially, researchers weren’t reporting information that could tell
practitioners if the research-based interventions and outcomes could be generalized to typical community or
clinical settings, or to typical client or patient populations.
Fortunately, things are changing and, based on current research databases, approximately 30 articles have
been published in the last 3 years that have explicitly used the RE-AIM framework within physical activity
promotion initiatives. This chapter employs a number of these studies to summarize different strategies that
can improve different dimensions of RE-AIM within different practice settings, and when possible, will
distinguish between the following three general types of physical activity promotion strategies. First, and most
common, are physical activity programs, which may be most beneficial to the physical activity promotion
practitioner. These programs include sessions or interactions for an individual to engage in for a finite period
of time. They can include, for example, in-person sessions with a personal trainer (52), small group meetings
(40), Internet or print-based materials (33), or telephone counseling (16). Second, are strategies aimed at
changing the environment to promote physical activity. While it is clear that many communities are in the
process of adding park or trail space, improving sidewalks, or using traffic calming strategies to improve
physical activity, there are relatively few experimental tests of these strategies (6,50). Third, are strategies
aimed at changing policy to promote physical activity. Policy approaches represent another emerging area in
physical activity promotion. Policy approaches can include the implementation of medical guidelines (17),
changes to school wellness policies (4), or zoning laws (44). Few experimental studies exist that examine
policy changes. In fact, if you are implementing policy and environmental changes, you can aid in the creation
of evidence using the RE-AIM framework.
In each of the following sections is a list of planning strategies to optimize each of the RE-AIM
dimensions in your physical activity promotion program. It is important to note, that some of the ideas for
improving one dimension could have negative consequences on another dimension. A good example of this is
the suggestion that program Reach can be improved by making the intervention less intensive (e.g., lower
frequency of meetings; low time commitment). Conversely, it has been suggested that more intensive
interventions are needed to see large changes in behavior (53). More specifically, a physical activity promotion
program that requires only one initial in-person meeting and follow-up telephone calls could be delivered to a
lot more people than one that requires exercise classes three times per week, a 2-hour group problem-solving
session every other week, and follow-up telephone calls. On the other hand, the intervention with all the
exercise classes and group meetings will probably result in bigger changes in behavior but reach fewer people.
We anticipate that you will encounter some of these issues as you plan your program, and our advice is to plan
what you or your organization values most (e.g., reach vs. effectiveness)—while still trying to optimize across
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dimensions when possible.
Reach
Working from the definition of Reach provided in Table 9.1, the first decision that needs to be made when
planning your program is: What aspect of Reach is most important to you? In research settings, it is likely that
the most important aspect of Reach is representativeness. For research evidence to be applicable to practice
settings, the people that are included in a study should be representative (i.e., share the same motivational,
demographic, and behavioral characteristics) of those typically served in practice. In practice settings, an
initiative’s success is often based (a) on the appropriateness of the initiative in responding to community
needs, and (b) on the total number of people that participate regardless of their current level of physical
activity, race/ethnicity, or socioeconomic status, so the context of your intervention will contribute to your
decision about what aspects (maybe all of them!) of Reach to target for improvement.
Think about a physician in a clinic who has 1000 patients who are not meeting the recommended
guidelines for physical activity. Her goal is to get all 1000 patients to participate or benefit from her physical
activity strategy. Alternatively, a community health worker may be required to have a certain quota of clients
at any one time and may, therefore, focus solely on the number and characteristics of the people he works with
to ensure meeting his quota. Finally, if you are offering a fee-for-service program, then understanding how to
increase numbers and track characteristics to identify groups that may not be responding to your recruitment
efforts is critical.
An obvious starting point to increasing Reach is to consider how you will advertise your initiative. Mass
media approaches are often quite successful in bringing in participants to a physical activity program (49), but
their success often depends on your resources and setting. If you are looking to be efficient with your
resources, and are recruiting for your program in cities, the mass media approach can work very well; however,
if you are recruiting in rural areas, often more personal (and strategic) word-of-mouth strategies work better
(49). Similarly, when you are trying to recruit minority populations or groups that have health disparities,
strategies that are place-based (e.g., going to where the participants are) and reaching out directly to potential
participants is better than flyers, posters, or other less interactive recruitment strategies (39). Furthermore,
when considering the cost per participant that enrolls in your program, holding events where your target
audience already aggregates is one of the least expensive ways to successfully recruit participants (36).
A less obvious approach to improving Reach is to consider the characteristics of your facility or program. In
one of the authors’ ongoing studies, two community-based physical activity programs were compared (26).
One of the programs included an evidence-based approach where participants met as a group for 90 minutes
each week for 12 weeks. The other program didn’t include weekly meetings, but focused on group goal setting
that was intended to bring all participants to the recommended 150 minutes per week of physical activity over
an 8-week period. Results showed that the second program recruited nearly four times the number of
participants when similar advertising strategies were used. The implication is that a program that has regular
classes, allows participants to do activities when they want, and encourages setting goals with friends and
families is more attractive (and may have less obstacles) than a program that has regular weekly meetings at a
set time and location. Even more drastic improvements in Reach can be achieved by implementing policy and
environmental changes. The key to improving your likelihood of a strong Reach is to determine who will
consistently be exposed to the changes. For example, in the Healthy Youth Places program (an intervention
that targeted increased physical activity and healthy eating in middle school children), changes in policy
around a health education curriculum ensured that all students in the intervention sessions were exposed to
effective strategies to promote physical activity (15).
How do you evaluate the Reach of your program? Determining the Reach includes tracking the number of
participants or clients, the proportion of the target population that participates, and ensuring that you are
getting participants from all sub-groups of your target population—especially those who could benefit most
from your intervention or expertise. While tracking the number of participants is a straightforward process,
identifying the proportion and representativeness of program participants can be a little more complex. To
determine the proportion of the target population that participates, understanding the denominator is key.
This can be relatively easy if your program or policy is being implemented in a defined setting (e.g., health care
clinic, school, church) where there is a concrete record of the number of people that could participate. In one
trial to promote healthy eating, physical activity, and weight control for people at risk for diabetes, all of the
patients in a health care system were included as the denominator and found that about 8% (approximately
1000 patients) were reached by our diabetes prevention efforts (1). Calculating the denominator becomes a
little more challenging when your program is promoted through mass media or word-of-mouth. Still, even a
reasonable estimate is valuable information, and can help to identify what types of strategies are best for
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getting a large proportion of your target population to participate. For example, when using newspaper or
television advertisements, working with a media representative to get estimates of reader/viewership numbers
can be used as a reasonable estimate for a denominator. In fact, most media outlets publish this information
online to encourage advertising. An alternative method is to simply determine the number of people in your
community who are eligible for your program and use that as the denominator. In Walk Kansas, a
community-based physical activity program, the total adult population in the counties where the program was
delivered was used as the denominator (20). In the first year the program was delivered, approximately 1% of
the population (approximately 6000 people) participated. These two examples are provided to demonstrate
that proportional Reach in community and clinical interventions may be very small (e.g., 1%, 8%) but still
indicate successful recruitment when specific participant numbers are considered.
From an environmental or policy perspective, it may be hard to deduce exactly how many individuals are
affected by environmental changes (34,37); however, Reach can be estimated by determining the number of
the target population exposed to the policy or environmental change. This can be calculated with a number of
tools (e.g., observational audits, market surveys, land use audits, etc.) (34,37,35). To determine the
denominator, you can measure the total target population within a certain buffer zone of the environmental
change. An example for policy change would be to identify the number of children who are in schools with a
certain local wellness policy. Many databases, like the U.S. Census and geographic information systems, can
provide population estimates regarding buffer zones and, in settings like schools, publicly available data on
school size and child eligibility for free or reduced-price lunch (an indicator of economic status) can be used
(34,37,45). Finally, to determine representativeness, completing comparisons of key characteristics of those in
the targeted intervention area with those who are exposed to the environmental or policy change can help to
uncover any potential gaps (see Table 9.2 for examples).
TABLE 9.2 Key Characteristics to Determine Representativeness
Demographic Characteristics Behavioral or Health Characteristics
Age % Moderately and Vigorously Active
Gender % Sedentary
Race and Ethnic Background Fitness and Strength Level
Socioeconomic Status General Health
Education % with or at risk of chronic conditions that can be improved through physical activity
Health Literacy Level
Effectiveness
Within RE-AIM, the “E” can represent either efficacy or effectiveness. Efficacy refers to how well an
intervention works when it is tested under optimal conditions (e.g., in a university medical center).
Effectiveness refers to how well an intervention works in real-world settings. Because this book is targeted
toward health professionals working with participants, we will stick with the real-world version and use the
term Effectiveness. Effectiveness includes not only how well your program can increase physical activity, but
also the degree to which it influences the quality of life for your participants. In addition, focusing on safety is
key when promoting physical activity. Recently, the American College of Sports Medicine (ACSM)
published a position statement that outlines not only the recommended amount of physical activity, but also
strategies to improve safety and avoid injury across different segments of the population (29). Practitioners are
encouraged to review that position stand for detailed information on safety issues related to physical activity
prescriptions (24).
There have been a number of systematic reviews on the Effectiveness of physical activity promotion
interventions over the previous decade (7,18,35,48). Findings suggest that interventions that use behavioral
approaches to tailor intervention content to participants are more successful than those that do not use
tailoring. Similarly, social support or group dynamics–based interventions consistently lead to increases in
physical activity. There is less evidence for physician-based counseling, unless it is partnered with community
resources to support physical activity.
Related to this, improving access to physical activity resources also has a positive influence on behavior. In
fact, many of the chapters in this book highlight the cutting edge of effective interventions for increasing
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physical activity. Understanding the relationship between policies to promote physical activity and an increase
in the behavior reflects a gap in the current research base. As with Reach, when planning what strategies to
employ to increase physical activity in your target population, it is important to align your activities with your
organizational mission and resources. There are many effective physical activity strategies available. Take the
time to find the one that is best for your situation.
As with Reach, there are a number of ways to measure the Effectiveness of your program or initiative. Your
job is to determine the type of information that is likely to be sufficient for your key stakeholders (e.g.,
funders, administrators, participants). No doubt you will want to assess changes in physical activity. But how
is this done? Most community programs use self-report measures of activity before and after the program. To
try and reduce the burden to participants or clients, physical activity measures (32) can be included as part of
the registration documents. You may also want to introduce a direct measure of physical activity on a
randomly selected subset of your participants (see Table 9.3 for examples), though this may not be practical if
you are reaching a large number of participants and have limited resources.
Measuring quality of life and potential negative consequences can also be completed with brief self-report
measures. Using the Center for Disease Control and Prevention’s Healthy Days measure (see From the
Practical Toolbox 9.1 for the measure and www.cdc.gov/hrqol/pdfs/mhd.pdf for a full description) is a good
selection as it is brief (four items), and allows you to compare your program outcomes to a national sample
(42). This measure can also be integrated into a registration form and follow-up assessment for your clients.
Measures for potential negative outcomes can include simply tracking client injuries or changes in other health
behaviors. One example could be adding physical activity promotion to an ongoing nutrition program.
Measuring nutritional changes in clients before and after the new physical activity strategies are implemented
can help to determine if the additions reduced the Effectiveness of the nutrition education components of the
program (12).
TABLE 9.3 Possible Measures to Include When Assessing Effectiveness
Measures Examples
Direct Physical Activity Measures Pedometers

Accelerometers
Self-reported Physical Activity Measures International Physical Activity Questionnaire (IPAQ)

Godin Leisure-Time Exercise Questionnaire (GLTEQ)
Physical Activity Survey for the Elderly (PASE)
Yale Physical Activity Survey (YPAS)
Quality of Life Measures CDC Healthy Days

SF-36v2 (RAND-36)
Quality of Well Being Scale (QWB, QWB-SA-self-administered)
Health Utilities Index (HUI)
Follow-up assessments are ideal but often difficult for community and clinical groups to complete. Your
goal should be to obtain follow-up on as high a proportion of clients who begin the program as possible (e.g.,
>70%). One way to aid in getting higher response rates to follow-up assessments is to build physical activity
assessment into the intervention itself. For example, most programs include developing some form of goal
setting and feedback process that includes having participants report physical activity levels periodically
through the program. By using the same physical activity measure that was used on a registration form, a
program can be evaluated by comparing client reports over time. The authors have found in their work that
making the evaluation easy to complete by offering different methods like paper and pencil, Web-supported
measures, and telephone interviews can lead to high follow-up rates. Using a stepped approach to getting
follow-up assessments using these different methods always works well.
For the ongoing program, Fit Extension, all participants get a paper version of the follow-up evaluation and
a link to an online version during the last week of the program. Over the 3 years this approach has been used
with this first step resulting in approximately a 50% response rate. Those who don’t respond receive a second
step that includes an e-mail prompt with a link to the follow-up assessment. The e-mail expresses
appreciation for participation, the value of evaluation to improve the program, and recognition that
the participant may not have time to complete the assessment online. In the latter case, participants are told
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they can complete the evaluation during a follow-up telephone call that will come in a few days. This message
gets on average an additional 15% of participants (up to 65%). Finally, telephone contacts are made to the
remaining 35% of the participants, and an additional 10% respond, for a total response rate of about 75% of
the participants.
For environmental and policy approaches, measuring Effectiveness is more difficult, but not impossible. If
possible, identify an appropriate physical activity measure and observe and map the population behavior
occurring before and after the environmental change (a pre- and postassessment) (37). For example,
observations of community resident walking patterns can be monitored before and after a sidewalk
development and improvement initiative.
For policy changes, random samples from the population exposed to the policy could be used to assess
physical activity levels before and after the policy is implemented. A drawback to the random sampling is that
you may miss legitimate changes in physical activity if the policy or environmental change has influenced
some but not all of the population. It may be appealing to do more strategic prepost assessments with groups
that the policy or environmental change is most likely to impact. Going this route has its drawbacks, too, but
as long as you document how you did the evaluation and why you made the strategic decision, you will get a
clearer picture of who was (and wasn’t) influenced by your change.
CORE HEALTHY DAYS MEASURES

1. Would you say that in general your health is excellent, very good, good, fair, or poor?
2. Now thinking about your physical health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health not good?
3. Now thinking about your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not good?
4. During the past 30 days, for about how many days did poor physical or mental health keep you
from doing your usual activities, such as self-care, work, or recreation?
Reprinted from www.cdc.gov/hrqol/pdfs/mhd.pdf.
Planning for Adoption

Adoption is about designing an intervention to enhance its potential to be disseminated and used by various
settings and delivered by staff with certain levels of expertise. If you work in an organization with multiple
health professionals who could implement your intervention, then understanding how you can get each person
to adopt and begin delivering the program is an important aspect of RE-AIM for you to consider. There has
been very little experimental research to determine factors that influence Adoption of physical activity
programs; however, there is a large body of literature that summarizes Adoption decisions in other
organizational contexts (Table 9.4) (43). For some practitioners, Adoption may be a RE-AIM dimension that
is of lesser relevance. Many practitioners are concerned about their own practice and focus on how to make
their programs work better, reach more people, and be sustainable in their specific setting.
TABLE 9.4 Program Characteristics that Positively Influence Adoption5
• Low complexity (i.e., not lots of different parts)
• Ease of understanding
• Compatibility with organizational norms and values
• Low need for a large organizational time commitment
• Associated with a strong evidence base that limits the risk of poor or uncertain results
• Observable in terms of results
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• Easy to test out and stop if necessary
• Able to be updated and modified over time
Adoption is also more likely to occur when incentives, training, and organizational structures are addressed
(5). Aligning your physical activity program with the specific workflow of your organization will also improve
Adoption. For example, adding prompts within the electronic medical record to cue physician referrals to
physical activity resources in the community could improve Adoption (2). Finally, current research documents
that collaborative development of a physical activity initiative with health professionals from the systems
where the program is ultimately to be adopted can increase Adoption rates significantly. The underlying
principle is that if the people who deliver an intervention contribute to its design, it is likely that the design
will fit well in that setting and those who deliver it will feel a sense of ownership for the initiative.
When instituting an environmental or policy change, it may be helpful to consider planning and approval
stages (37). Many of these changes require advanced planning, and it will be helpful to track how many
organizations, residents, and members of the target population are included in the initial planning. Also,
understanding what agencies and organizations approve the change, and engaging them in action steps to
complete the changes, is critical. Finally, although this may go without saying, it is key in making
environmental or policy changes that all those who will be influenced by the change, or needed to implement
it, are included in the planning and approval process (37).
Evaluating Adoption includes many of the same considerations that were used to assess Reach—with the
caveat that Adoption is at the level of the organizations and health professionals delivering a program or
implementing a policy or environmental change. The 10,000 Steps Rockhampton project provides a good
example of examining both practice and health professional Adoption of a physical activity program delivered
through primary care practices, and also demonstrates the dynamic nature of evaluating physical activity
programs (17). The researchers identified that there were 66 general practitioners in 23 clinics in
Rockhampton as potential individuals and locations to deliver the program. Of course, over the course of the
project new general practitioners took up practice, some ceased practice, and by the time Adoption was
assessed using in-person visits to the clinics, there were 55 total general practitioners employed.
The clinical Adoption rate was very high for the project in that 21 of the 23 clinics participated. Within
clinics, the proportion of general practitioners that had adopted the program was 58% (i.e., 32/55). To
determine representativeness of the general practitioners and clinics, the research team compared those clinics
and physicians who participated on the only two publicly available characteristics, the number of physicians
per clinic, and the gender of the physicians. They found that the number of physicians per clinic was the same
for those that participated versus those that did not. They also showed that male and female physicians were
just as likely to offer the program (17).
It is somewhat more difficult to determine the rate of Adoption and representativeness of organizations or
individuals who adopt policy and environmental changes. Indeed, as noted earlier, if your focus is on a single
community, a single location, or a single organization, your rate of Adoption doesn’t have much meaning (i.e.,
it will always be 100%). In these situations, it will be much more important to focus on Implementation as
described in the next section. Some have suggested that the denominator in each stage of an environmental or
policy intervention should be the total number of agencies and organizations invited to contribute to making
the change happen, rather than those that will ultimately be responsible for implementing the strategy (37).
For instance, a researcher may invite the following organizations to help plan, approve, and implement the
addition of a public playground in low-income housing: mayor’s office, city legislative body, city public
housing manager/department, affected citizen coalitions, residents, playground manufacturers, etc.; however,
only three (the city public housing manager, residents, and playground manufacturers) may be interested in
participating in each Adoption stage. The actual number of agencies participating will be the numerator (37).
In these cases, it may be most helpful to divide partners into those who can contribute to planning (e.g., all six
contacted as the denominator; 6/6 for planning), those who can generate resources (e.g., four of the six, but
only three do so; 3/4 for resource generation), and those who will be involved in the implementation (e.g., 3/3
as described earlier).
Implementation
Implementation is sometimes confused with organizational Adoption. The best way to distinguish between
the two is to consider Adoption to be the process of deciding whether or not to deliver a program or institute
a policy and initiating the first action to do so. Alternatively, Implementation is the ongoing process
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associated with program delivery or monitoring of policy adherence. Using the Rockhampton example from
earlier, Adoption was based on the clinics and physicians that agreed to participate in each aspect of the
program (17). Implementation was assessed as the degree to which they followed through on that agreement
(17). The key concept associated with Implementation is that it reflects the extent to which your initiative gets
put into action the way it was intended.
In one simple example, the Implementation of the WellingTONNE Challenge Toolkit—a step-by-step
toolkit for health professionals and community groups to describe how to develop and implement a healthy
lifestyle community intervention—was simply reported as 98% of the health professionals who received the
toolkit indicated they were using it to encourage healthy lifestyle behaviors in the community (8). A more
complex description of Implementation comes from the Exercise Your Options program that reported 86% of
teachers indicated they delivered all eight lessons, and classroom observations confirmed that teachers were
delivering between 81% and 100% of the content in each lesson (13).
There is a large body of literature on factors that facilitate or inhibit successful program Implementation
(see Table 9.5) (9). Within the physical activity domain, the Well for Life trial used external program
evaluators to determine positive and negative influences on program Implementation (41). In their program,
which targeted older adults, they found that the presence of champions who encouraged participation, high
commitment from management and staff, preexisting relationships between the Well for Life developers and
health care systems, and access to funds to purchase equipment all improved Implementation. Similar to
Adoption, if the benefits of Well for Life were promoted, it may have improved Implementation. Not
surprisingly, time constraints and lack of staff continuity were negatively associated with Implementation (41).
School-based environmental change and policy interventions all seem to have similar barriers to successful
Implementation. In the JUMP-in school-based physical activity intervention, Implementation was reduced
when teacher workloads were high, there was little cooperation between schools, physical education teachers
were unqualified, and when the intervention guidelines were not well understood (11). When considering
environmental change interventions, it is necessary to identify standards and guidelines of the environmental
change (37). This includes anticipating community concerns and backlash, barriers, and any delays that might
affect costs (37).
To evaluate Implementation, you need to have a strong understanding of the specific components of your
intervention or program, the resources used, and the amount of staff and time dedicated to delivering the
program. The primary components of assessing Implementation are the degree to which the program is
delivered as intended and the costs associated with that Implementation. At the broadest assessment of
Implementation, you can simply track if all of your intervention sessions were completed. If you are using
small group sessions, you could report, for instance, that 10 of 10 planned sessions were offered at the
designated time. If you are using mail support or education, you could track the number of mailings that were
delivered when intended and report the proportion of those that were not returned unopened (e.g., if the
address was incorrect or changed). Occasionally, this information may not be all that helpful or informative.
From the authors’ experience with community partners, if sessions are set up they are delivered unless there
are extraordinary circumstances (e.g., a snowstorm that closes roads; a printer breakdown at the office). You
may find it more helpful to track the degree to which participants actually receive the program materials as
indicated through class attendance or reports of getting the mailed intervention content.
TABLE 9.5 Factors that Can Facilitate or Inhibit Implementation
Factors Examples
Intervention Characteristics The perceptions of key stakeholders regarding internally/externally developed intervention
The quality of evidence arguing the intervention’s success
The relative advantage of implementing the intervention versus an alternative
The adaptability of the intervention
The perceived difficulty to implement the intervention
The design quality and packaging of the intervention
Intervention costs
Organization’s Outer The ability of the organization to meet patient needs

Setting The organization’s ability to network with external organizations
Peer pressure to implement the intervention
External policies and incentives that can spread the intervention
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Organization’s Inner Structural characteristics of the organization (age, size, and maturity)
Setting The quality of informal and formal networks within an organization:
Organizational culture
The implementation climate of the organization
The readiness of the organization for program implementation
Individual Characteristics Attitudes and values of individuals regarding the intervention

within an Organization The individual self-efficacy to execute aspects of the program
The individual’s relationship with the intervention (which stage of use is the individual at)
The individual’s relationship with the organization
Other attributes like personal motivation, competence, capacity, and learning styles
Process Elements Degree of planning involved to implement the intervention, and;

The engagement of appropriate individuals (opinion leaders, formally appointed implementation leaders,
program champions, external change agents) to implement the intervention;
The execution of the implementation according to plan
Quantitative and qualitative feedback regarding implementation progress
Another important aspect to track in Implementation is the degree to which each program session or
contact contains the content that was intended. In the Gimme 5 intervention conducted in Georgia, the
Implementation evaluation involved determining how much of the intervention curriculum was delivered as
intended. This determination can be completed using self-reports from the people delivering the intervention
or randomized observations of classroom sessions. In Gimme 5, they found that only half of the curricular
activities intended to be delivered in schools were actually implemented (10). Parents were also a key in the
intervention and very few parents received the information delivered during evening classes (<10%) (10).
Tracking costs and resource use can provide useful information on areas that you may focus on to increase
the efficiency of your program offerings. Cost data can be gleaned by converting salaries to per-hour costs of
those implementing the intervention, determined through tracking material costs, and monitoring indirect
costs (e.g., space rental, air conditioning). By monitoring the cost of each program component and
implementing a good effectiveness evaluation, practitioners can test out different delivery models that reduce
costs without reducing effectiveness.
Evaluating the Implementation of policy and environmental changes focuses on the degree to which the
environmental change is conducted according to planning documents, and a policy is applied as intended. For
an environmental change, while ongoing monitoring and upkeep will likely be necessary, Implementation
evaluation is typically concurrent with the completion of the environmental change. Policies, however, include
plans for enforcement and ongoing compliance with the core components of the policy (34). Though
somewhat burdensome, local audits in areas where the policy has been adopted can be used to determine the
degree to which the policy has been implemented. Monitoring of policy evaluation language and interviews
with key stakeholders can also be used to assess the degree of compliance related to policy components.
Maintenance
As with Effectiveness, there are now emerging systematic reviews on the Maintenance of individual levels of
physical activity once an intervention is complete. Most recently, Fjeldsoe and colleagues examined the degree
to which physical activity and dietary interventions result in maintained behavior change at least 3 months
after the initial program was complete (27). About a third of all studies since 2000 included data on
Maintenance and the primary findings suggested that there are a number of characteristics of interventions
that could be modified to improve Maintenance. Interventions that lasted 6 months or more were more likely
than shorter programs to result in maintained physical activity.
Somewhat related to this, programs that included follow-up prompts once the formal program was
complete were more likely to lead to behavioral Maintenance. In addition, while interactive technology–based
interventions were often effective in maintaining behavior changes, any intervention (including interactive
technology–based ones) that included some face-to-face contact with those delivering the program were
significantly more likely to result in longer-term changes in physical activity. Interventions that target women
carefully screen volunteers so as to include only those most likely to adhere and are also more likely to result in
maintained behaviors. Although both of these factors are more likely due to the motivational characteristics of
the final sample than due to program content (27).
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As with Effectiveness, the use of brief physical activity and quality of life measures and, when practical,
direct measures on a subsample of the population can provide the data necessary to document Maintenance of
physical activity changes. You can also apply similar follow-up assessment methods that use a stepped-
approach (as previously mentioned in the Effectiveness section of this chapter). To assess the maintained
influence of environmental and policy approaches, it is appropriate to use the same measures and methods
that were completed to assess the Effectiveness immediately post-implementation. A good timeline for
program, policy, and environmental change assessments is every 6 months after the program ended or after
the policy or environmental change was implemented.
There is much less information on organization-level Maintenance of physical activity program delivery,
but based on research in other areas there are a few key strategies to improve sustainability in community or
clinical organizations (25). Specifically, generating evidence that your program can reach a broad cross-section
of participants and effectively increase physical activity can be very helpful in highlighting success with key
stakeholders. This information can be adapted into materials that can promote the program to future
participants and organizational decision makers who can determine if a program is offered in the future or
not. As sustainability is often jeopardized by reductions in funding (41), the development of a funding
development committee and integrating the program into existing operations are important for sustained
programs. Community engagement and the support of program champions can also significantly improve the
chances of sustainability (25).
One of the benefits for using ongoing implementation evaluation is that it can double as an assessment of
program sustainability. If a program continues to be implemented, it is an indicator of sustainability. Using
the Implementation assessment can also provide indications of adaptations that were necessary to improve the
likelihood of sustainability. The timing of sustainability assessment should probably occur on an annual or
semi-annual basis.
Step-By-Step Re-Aim Evaluation
The authors have developed this step-by-step process for completing a RE-AIM evaluation of your physical
activity initiative, keeping in mind that your initiative could be a program, environmental change, or policy.
They also direct readers to the RE-AIM Web site (www.re-aim.org) for general information about the
framework and clarification. The Web site includes detailed descriptions and evaluation examples as well as
some checklist and calculation tools that may be helpful for you. When appropriate, in the following sections,
specific links to relevant content are provided. RE-AIM was initially titled the ARI-EM framework to align
with a practical assessment of programs from Adoption, to Reach within the adoption sites, to
Implementation, to Effectiveness as a result of Implementation, and then finally focusing on Maintenance
once effectiveness is achieved (28). The following instructions will follow this pragmatic order.
Step 1: Adoption
a. Determine if you need to monitor Adoption. If you are a sole operator in your organization (e.g., health
educator in a community health center) and you are trying to improve your effects with your clients, you
will not need to track Adoption and you could move on to Reach.
b. Identify the total number of settings where you think your program could be delivered. To help with this
estimate, go to http://www.re-aim.hnfe.vt.edu/tools/links/index.html#data where you will find links to
databases for estimating schools, worksites, health care, civic, and community organizations that are in
your particular area.
c. Determine if there are characteristics of those settings that could influence the likelihood of program
delivery and locate available information on those settings. For many settings, the client/health
professional ratio, the number of health professionals per setting, the socio-economic make-up of the
census tracts that reflect the catchment area for the setting, and the time the setting has been operating are
all variables that could influence Adoption. See the link in part b earlier for data resources to obtain this
type of information.
d. Invite the representatives from local settings to participate in delivering your intervention. Count the
number that agree and the number that do not. Create a proportional indicator for Adoption.
e. Compare the settings that agree to deliver the intervention to the information you gathered on all eligible
settings (i.e., point “c”). This does not have to include sophisticated statistics, just simple comparisons
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(e.g., those churches that agreed to participate had congregation sizes of approximately 150 compared to
congregation sizes of approximately 300, on average, for those that declined).
f. For each setting that agrees to participate, determine if there are multiple health professionals that will be
expected to implement the strategies. If so, determine the denominator of health professionals in each
participating setting. Identify specific characteristics about the health professionals (on average is fine).
Age, gender, physical activity status (if available), race, ethnicity, years in the field, and level of expertise
are all useful characteristics. Invite all health professionals to deliver the program; track the number that
agree and the number that do not to create a proportional health professional Adoption measure. Again,
compare characteristics of those that agree to participate with the average characteristics in each setting.
g. For policy or environmental changes, identify and invite various organizations that have interest in the
environmental change (public works, parks and recreation, etc.), and the agencies / key stakeholders that
could participate in the planning, approval, and implementation stages. To measure the rate of Adoption,
use the total number of agencies invited to the planning, approval, and implementation stages as the
denominator and those that engage as the numerator. Rather than comparing to an aggregated group of
similar agencies (as we did with settings earlier), determine representativeness based upon the degree to
which you were able to attract all of the key stakeholders necessary to make the Adoption decision.
h. To complete the assessment of Adoption, record the number of settings and health professionals that
agreed to deliver your program or participate in planning/implementation of your environmental or policy
change. Record the percent of those eligible that engaged at both the setting and health professional level
(see http://www.re-aim.hnfe.vt.edu/resources_and_tools/calculations/adoption_calculator/index.html for
an Adoption calculator to help with this). Report the degree to which you were successful in getting a
representative sample based on the available setting and health professional information.
Step 2: Reach
a. Identify the total number of people who would be eligible for your intervention or program that receive
services or interact with the settings where access to the intervention is offered. Use the information found
at http://www.re-
aim.hnfe.vt.edu/tools/calculations/reach_calculator/finding_numbers_to_estimate_reach.html to aid in
estimating your denominator. The Web site also provides a description of methods to estimate the
proportion of people who were exposed to your recruitment activities.
b. Determine the basic characteristics of your target population using census data or other locally available
data (e.g., de-identified data from a clinic’s electronic medical record). Basic demographic information is
appropriate, but other behavioral or health status information can also help you determine if there are
subsamples in the population that are either over- or under-represented in your intervention.
c. Determine the number of people who respond to your recruitment efforts and begin your program.
d. Compare those that agree to participate in the intervention to the information you gathered on all eligible
people in your settings. As with Adoption, this does not have to include sophisticated statistics, just simple
comparisons (e.g., there is a smaller proportion of Latinos in our intervention than there is at the worksite
where we offered the program).
e. For policy or environmental changes, estimate the total number of people living and/or working within a
specific buffer zone around the proposed environmental change. Use intercept surveys to determine the
place of origin of individuals and observe and describe visitors during various times of day after
implementation of environmental change. For a government policy like tax breaks for children
participating in youth sports, the denominator would be all children in the area eligible for the breaks, and
the numerator would be those that actually took advantage of them. Use this setting-level data as a proxy
to track changes of Reach over time.
To complete the assessment of Reach, record the number of people that agreed to participate in your program
or interacted with your environmental or policy change. Record the percent of those eligible that engaged with
your intervention (see http://www.re-
aim.hnfe.vt.edu/resources_and_tools/calculations/reach_calculator/index.html for a Reach calculator to help
with this). Report the degree to which you were successful in getting a representative sample based on the
information available.
Step 3: Implementation
a. Identify the components of your intervention (e.g., small group session, followed by three tailored
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mailings, and six motivational interviewing based calls). Identify the key content in each of the
intervention components.
b. Track the extent to which each component of the intervention is delivered on time according to the
intervention delivery schedule. Use a checklist for health professionals to indicate the content that was or
was not covered during each intervention contact.
c. Calculate the proportion of the intervention that was delivered as intended (i.e., what was delivered as the
numerator and what was intended as the denominator).
d. When determining the Effectiveness of the program, examine differences based on the percent of the
program that was delivered as intended. Similarly, track all costs associated with the intervention and use
this to consider potential areas to create efficiency without reducing key content.
e. Track any adaptations to the intervention that were completed to make it more suited to your setting, the
expertise of the staff, or the interests of potential participants. Include Effectiveness assessments before
and after any significant adaptations.
f. For environmental or policy changes, identify standards or guidelines for your changes as well as develop
and use planning documents. Determine the degree to which the change aligned with planning documents
and guidelines. Similar to program implementation evaluation, track all costs associated with the change.
Step 4: Effectiveness
a. Select an appropriate measure of physical activity. Ensure that the measure aligns with the type of physical
activity you are promoting and includes an assessment of frequency, intensity, and duration. Use a
validated measure rather than making up your own. On a subsample of your group, when possible, use a
direct measure of physical activity.
b. Select appropriate measures for quality of life (see CDC Healthy Days measure) and unintended
consequences (this can simply be the tracking of minor and major adverse events).
c. Assess physical activity and quality of life before the program begins and when the program ends. For
more accurate accounts, collect reports of physical activity on a weekly basis using telephone or online
tracking. Compare changes in physical activity changes in quality of life and potential negative outcomes.
d. Track participant attrition (i.e., what proportion of those that began the program dropped out before it
ended).
e. If a large proportion of your participants do not complete the follow-up assessment (e.g., >30%), use a
simple procedure that uses the baseline value as the follow-up value for those that didn’t complete the
assessment to give a more conservative estimate of your program’s effectiveness. This is a form of an
intention to treat analysis.
f. Using data collected for Reach, determine if there are differential effects of the intervention for different
subgroups in your sample. Also examine if participants who dropped out were different than those that did
not. In particular, examine differences based on initial physical activity level, gender, race/ethnicity, and
economic status.
g. Using data collected for Implementation, determine if effectiveness is influenced by the degree to which
key content was delivered as intended to the participants.
h. For environmental or policy changes, replace individual assessments with physical activity audits in the
setting where the change occurred. When possible, also assess before and after to determine if the change
is influencing different groups within the target population.
Step 5: Maintenance
INDIVIDUAL LEVEL
a. At the individual level, Maintenance assessment is a continuation of effectiveness assessment. It includes
assessing participants some time after the formal intervention is completed, usually 6 months after it is
completed.
b. Follow steps e–h of Effectiveness 6 months after the program is complete or the environmental or policy
change has been in place.
ORGANIZATIONAL LEVEL
a. Maintain contact with those who are delivering the intervention over time. Track the number of times a
program is offered and continued Reach as an indicator of sustainability.
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b. Conduct brief interviews with those implementing the intervention to determine if adaptations have
occurred, if there are plans to continue delivery, and if there have been expansions or contractions in
delivery.
c. Brief interviews can occur on a pragmatic schedule. If a program is 6 months long, tracking on a semi-
annual basis would make sense. If a program is 8 weeks long, tracking would need to occur more
frequently.
d. Record the ongoing number of times the program is offered and the Reach of each specific offering.
e. For environmental or policy approaches, determine if there have been plans for upkeep or enforcement and
the degree to which those plans have been followed to determine setting or organizational sustainability.
There are so many different types of physical activity initiatives that can be evaluated using the RE-AIM
framework. Case Scenario 9.1 presents a realistic, community-wide approach. It can include program, policy,
and environmental change strategies, is recommended as an evidence-based approach to improving physical
activity, and has been the focus of RE-AIM evaluations previously (35,47).
Case Scenario 9.1
glenda/Shutterstock.com
The physical activity initiative is located in a small community within a larger municipal area. The
school system is a focal point for the initiative, which plans to change elementary, middle school, and
high school policies to include regular physical education every day for all children. The authors plan to
align the curriculum with a community physical activity challenge that includes weekly newsletters, team
goals, and weekly group feedback. By aligning it with the in-school curriculum, they hope to encourage
families to engage in the challenge together. Finally, the authors are planning to work with the school
district to allow the school physical activity facilities to be open to the community after hours.
STEP 1: ADOPTION
Because the goal is to make changes in six schools (in our fictional community, there are three
elementary schools, two middle schools, and one high school), and attract all adults in our community to
participate, it is important to monitor Adoption. The six schools have been identified as places where
the initiative will be delivered, along with the local churches (four of them) and health care clinics (three
of them) to help reach a broad audience of adults. The target community does have some differences:
two of the elementary schools and one of the middle schools have approximately 90% of their students
eligible for free or reduced-cost lunches, whereas the high school is having problems passing federal
standardized testing and could lose some of its funding if things don’t improve. Otherwise, the
elementary schools are about the same size, as are the middle schools. As for clinics, one is a community
health center that serves Medicaid-eligible patients exclusively. The other two are associated with the
local hospital system. The churches are all about the same size, but one is Baptist, one is Mormon, one
is Catholic, and one is Methodist. To keep things simple, the congregations of each of the churches
have the same demographic and economic profiles.
The community group sends out invitations to each of the settings described earlier. The high school
declines the invitation, as do the Catholic and Methodist churches. All the elementary and middle
schools agree to participate. The community health center and one of the hospital-associated clinics also
agrees to participate. The rate of Adoption can be calculated by setting type (i.e., 50% of churches, 83%
of schools, and 67% of the clinics) or overall (69%).
There is a pattern that seems to explain why some settings decline. The high school administrators
and teachers are really focused on getting test scores up and feel any curricular changes that don’t teach
to the test are a bad idea. Both the Catholic and Methodist churches have just become involved in a
breast cancer awareness initiative and feel they can’t participate in another activity at the same time. The
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clinic that declines has just lost two physicians to retirement and is overloaded with their current
responsibilities. All of the declining settings have legitimate competing demands that put constraints on
their ability to participate. Luckily for our initiative, the settings that provide services to the lower
economic status members of the community do agree to participate, increasing the likelihood that we
will not miss this health disparate population.
There are 10 physicians in each of the participating clinics, for a total of 20, and one physical
education teacher (who will be responsible for the curricular changes) in each of the five schools. All of
the teachers are on board and excited about the new curriculum (100% Adoption). Of the physicians,
80% agree to participate by promoting the physical activity challenge to patients who are not meeting
the guidelines for physical activity and to do screenings for high-risk patients to determine the safety of
participating. The four physicians who decline are older and have been practicing longer, on average,
than those that choose to participate. For policy changes, the school district superintendent agrees to
support the curricular changes and make the school gym available after hours.
STEP 2: REACH
To determine the total number of people who will be eligible for the intervention, a choice has to be
made. For the present scenario, this could be the number of students in each of the participating
schools, the congregation size of the participating churches, and the number of patients at each of the
clinics. The problem is that the goal is to get the whole community active, whereas the churches and
clinics are just a way to advertise and help recruit people as opposed to delivering the intervention. In
addition, there is some likely overlap between the churchgoers and patients, which could add some
overestimation error to the calculation of the denominator. In this scenario, the census numbers for
adults and school-aged children in the community is the best denominator. Census data are also used to
determine the racial/ethnic breakdown in the community, the prevalence of poverty, and other
demographic information. Using this and the state reports for the proportion of people meeting
recommendations for physical activity, the sample is able to be described very well. In the end, our
denominator is 3000 children and 15,000 adults.
School-based curricular activities reach 2000 of the 3000 children (the 1000 missing are those in the
high school). As the physical activity challenge approaches, materials are sent home with the children,
physicians make referrals to it, and announcements are made at the churches and placed in the church
bulletin. In addition, presentations are conducted at the churches, and potential participants are allowed
to register on-site. Finally, ads appear in the local newspaper, and posters are hung all over the
community.
Prior to launching the challenge, 3000 adults enroll. Eighty-five percent of the adult respondents are
women, most have a child in one of the participating schools, and the average household income is
slightly higher than what is seen in the census data. Latino and African American women are just as
likely to participate as Caucasian women, but minority men are less likely than Caucasian men to
participate. When evaluating the policy change of making the school facilities available in the evenings,
nearly 300 men, balanced on race and ethnicity, are gathering regularly to play basketball. It is noted
that the men who used the gyms live, on average, within four city blocks of the school. Based on these
data, Reach can be reported based on children (67% proportional Reach), adults (22%), or both (29%).
The researchers are quite successful in engaging people across different household incomes but are not
very successful in getting a large proportion of men involved.
STEP 3: IMPLEMENTATION
Recall the intervention components include the school physical education policy and curriculum; open
access to school facilities after school; and the community-wide physical activity challenge, with weekly
newsletters, team goal setting, and feedback. For the curriculum, physical education teachers are
cooperative with the preparation for the challenge, but not with the delivery of the rest of the
curriculum. On average, they deliver about 50% of the material. For the adult portion, the physical
activity challenge is delivered just as intended, and 100% of the newsletters with feedback on goals are
sent out each week. About 5% of the mailings are returned with incorrect address or return to sender
marked on them, reducing the Implementation of this component to 95%. The implementation
numbers for children and adults are not combined because the separate numbers may be better to use
when testing for Effectiveness based on Implementation.
The costs of activities aren’t really clear. There is some concern at the schools that the utility bills
(e.g., heat and lights) will go up because the school is open later, but the information is never gathered
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from the schools. The cost of the physical activity challenge materials, and staff time in delivering them,
are tracked. Neither the physicians’ nor pastors’ time is included in the cost estimate because they donate
their time and are not involved in delivering any of the intervention. The researchers consider tracking
the time needed to recruit and to determine what the most efficient recruitment strategies are but decide
this is outside of the intervention Implementation evaluation.
STEP 4: EFFECTIVENESS
The researchers identify a validated and objective audit tool to determine physical activity to assess
student behavior before school, during physical education class, and after school. They also add some
brief and validated self-report physical activity recalls to the children’s school readiness package so they
can return them on the first day of school and the researchers can send them out again during the last
week of school. For parents in the challenge and men who are using the gym, we use brief, validated
self-report measures of physical activity prior to the first time the participant engaged in the program or
used the gym. Participants are asked to complete the CDC Healthy Days measure and a short
demographic questionnaire. The challenge participants are asked to report their physical activity weekly,
and for those that use the gym we assess physical activity every 6 months from their first day at the gym.
On each of the follow-up assessments, participants are asked about any injuries that may have occurred
as a result of increasing physical activity.
By the completion of the challenge, approximately 2000 people are still participating and do the post-
program follow-up. Because more than 30% are missing at the end, those people’s before-program data
are copied and used as their follow-up, too. This ensures that the researchers don’t overestimate
Effectiveness by assuming that people who don’t do the follow-up probably didn’t change their physical
activity. For the kids in the study, we get about 90% to complete the follow-up.
Adults have increased their physical activity by about 45 minutes per week on average, whereas
children have increased by nearly 120 minutes per week on average due to the new policy for more
physical education. Interestingly, adults who use the gymnasium have increased by 90 minutes per week
and report using the gym three nights a week on average. When looking across subgroups, it seemed
that the program works best for parents of children in the schools. Adults with lower household income
are more likely to be successful than those with higher income. When we consider Implementation,
students in schools with better Implementation are more successful at increasing physical activity.
STEP 5: MAINTENANCE
Individual Level
A year after the changes are first implemented at the schools, the students are still participating in more
physical activity than they were prior to the policy and curriculum changes. Adults that participated in
the physical activity challenge are still more active than before the program, but less active than they
were immediately after the program. The adults who did not do the challenge but used the open gym
space maintain their activity levels, likely due to the schools still being open in the evenings. Changes
have been maintained better in boys than girls for the students, but better for women than men in the
challenge.
Organizational Level
After the first year of the program, the researchers meet with the school superintendent, principals,
physical education teachers, pastors, and representatives from each of the referring health care clinics.
All enjoyed the initial year of delivery and are interested in trying a second year. There is a lot of talk of
small changes to the program and promotion, but everyone is ready to sustain the initiative. The
superintendent indicates that the access to schools after hours will be added to the school wellness
policy, and he will monitor the schools to make sure they adhere to the policy.
Take-Home message
It is highlighted again, although it is thought that each RE-AIM dimension is important and valuable,
they may not all be applicable in your context. Still, here are five take-home messages for you:
1. Pay attention to who is participating in your programs or who is reached by your policy and
environmental changes, know their characteristics and where you have gaps in reaching the breadth
of your target population.
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2. Track how participants with different characteristics fair in your programs, determine who it is
working for and, just as importantly, who it is not working for.
3. Reach and representativeness are often driven by adoption. If you only get settings that primarily
provide services to higher economic status and fewer minority clients, then the likelihood that you
will reach a full spectrum of your target population is very low.
4. Monitoring Implementation in an ongoing way to help you ensure your initiatives are being
delivered as intended. But as adaptations are made (as they invariably will be), it can also let you
know if adaptations influence effectiveness either positively or negatively.
5. Focusing on maintenance will let you know if your efforts lead to long-term changes and
demonstrate the value of your programs to your target population.
Changing physical activity is a challenging endeavor, especially when considering the issues
associated with implementing different strategies within real-world settings. This chapter intended to
highlight five areas of consideration that, if addressed and evaluated, can improve your chances of
having a large impact in your target population. It is likely that you have considered most of these areas
in your work at one time or another, and that by providing this information in a systematic way, with
step-by-step instructions and an example scenario, that you will be able to complete a RE-AIM
evaluation of your activities.
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Physical activity behavior change may be influenced by the health and fitness professional’s experience,
competence, and personal characteristics (2,4). The health and fitness professional must take time to
acquire and sharpen his or her counseling, communications, and professional skills and personal
attributes in order to facilitate physical activity behavior change. This chapter will focus on the practical
applications of professional skills, behaviors, and other factors that can facilitate or impede behavior
change.
Health and fitness professionals work in many different settings that include—but are not limited to
—fitness centers, community centers and nonprofits, worksites, and a variety of clinical settings. As a
result, the scope of practice for the health and fitness practitioner is broad and there may be considerable
variability in the professional standards of practice. The reader is referred to the American College of
Sports Medicine Guidelines for more details about the scope of practice of various health and fitness
professionals (1). However, there is foundational knowledge, skills, and professional behaviors shared
among health and fitness professionals that apply across the broad array of settings and professional
practice. This chapter will provide specific examples of behaviors, communication techniques, and
program design guidelines that the practitioner can put into practice in nearly any setting.
COMMUNICATIONS
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Verbal and Nonverbal Communications
The most successful professionals are aware of the importance of verbal and nonverbal communications in
their interactions with their clients, colleagues, and potential clients. Encounters should begin with a friendly
greeting accompanied with a smile, and eye-to-eye contact. Handshaking is customary in many settings, but
some people prefer not to shake hands due to concerns about health, religion, or other reasons. Therefore, the
health and fitness professional may want to allow the client to make the first move for a handshake, and take
the cue from the client. When shaking hands, it is important to have a firm—but not too firm—handgrip,
make direct eye contact, and say something like, “Nice to meet you, Mr. Jones.”
When conversing, the face and both shoulders should be squared toward the client (or colleague), at the
same time making regular eye contact. If seated, sit at or below the level of the client with a forward posture,
thus sending the message that the professional is entirely focused on the client. The voice should be in a
modulated tone that is audible to the client. The voice should be neither too loud nor too soft, and words
should be clearly annunciated at a moderate speed to facilitate hearing and understanding of the information
conveyed. Nonverbal indicators of active attention such as head nodding, judicious note taking, and hand
gestures can add to the quality of these encounters.
The health and fitness professional’s job is to educate, motivate, and promote physical activity and health
behavior change. Verbal communication skills are at the core of the practice. Whether on the telephone or in
person, what is said and how it is verbalized will affect how the client learns, receives information, accepts
feedback, and, ultimately, may influence their willingness to change behavior. The first rule for effective verbal
communication is that the practitioner must be committed to communicating effectively, and make efforts to
do so with each client and colleague.
Verbal communications are best when adjusted according to a client’s needs, capacity, and level of
understanding. It is always important to remember that individualization is key. Speaking clearly and audibly
in a pleasant tone and avoiding excessive slang increases the quality of the interaction and enhances
professional impression. Short silent pauses that can be used to gather thoughts are perfectly acceptable and
allow the client time to think about what has been said or to speak. Words and statements that may be viewed
as derogatory or harassing in any way need to be avoided at all times. For example, commenting on a person’s
clothing or physical appearance may be perceived as sexual harassment. Comments about an ethnic, racial, or
religious group, sexual orientation, body habits, or disabling condition can be perceived as derogatory. It is
helpful for all health and fitness professionals to undergo formal training in sexual harassment and cultural
sensitivity to enhance their effectiveness in working with diverse populations, and to increase awareness about
how communications may be perceived negatively.
Telephone and Electronic Communications

Following up after a session in the early phases of a training program (or at any time there may be major
changes or concerns) can do a lot to facilitate the development of rapport with the client, to provide social
support, and to promote behavior change. A telephone call made to the client 24–48 hours after the first
session can be very helpful. This allows the health and fitness professional an opportunity to check in with a
client to assess how they have responded to training, see if they are experiencing any problems related to the
exercise session, and to ask for feedback. This can also be done via e-mail depending on the client’s
preferences. Many clients may prefer electronic communications. The use of e-mail, text messaging, video
conferencing, Web sites, and social media can be effective for promoting physical activity behavior change (3).
It may also be beneficial from both a time management and record keeping perspective, and to maintain and
provide social support and an open line of communication with clients.
If e-mail is the preferred method indicated by a client, it is important to include a clearly identified subject
line to distinguish the source of the e-mail. For example, the subject line may include your name and title,
such as “From Susan C., Personal Trainer, follow-up on session.” It is particularly important when contacting
a first-time client that the subject line clearly identifies who the e-mail is from and its purpose. Also, the body
of the e-mail should include a brief introduction and the reasons for your communication (see Case Scenario
10.1 for an example).
Case Scenario 10.1
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Pavel Ignatov/Shutterstock.com
INITIAL COMMUNICATIONS WITH THE CLIENT

Sam is a certified personal trainer at a local health club, making first contact with a potential new client,
Mr. Jones, who has signed up for personal training services as part of his new membership. Sam has left
several voicemail messages for Mr. Jones, but he has not received a call back. Sam notices in Mr. Jones
membership application that he prefers receiving e-mail communications rather than phone calls. He
also notes that Mr. Jones is a 62-year-old man who is a high-level executive at a major company, so he
knows that Mr. Jones likely gets many e-mails each day and his may not be noticed. To increase the
likelihood that Mr. Jones will read his e-mail, Sam starts his e-mail with a descriptive subject line. He
then considers his e-mail content to ensure it is short and to the point, as is appropriate for e-mail
communications. He also incorporates behavioral principles into his communications, drawing from the
5 A’s counseling scheme and health behavior theories as discussed in previous chapters.
Sam writes his e-mail:
Subject Line: Your request for Personal Training Sessions at ExerClub
Dear Mr. Jones,
You have requested personal training at ExerClub. I would like to schedule a time to speak with
you to gather some information so you can get started. Please let me know when it may be convenient
for you to schedule a phone call. I have availability at many times during the day and evening and on
weekends, so I can work around your schedule.
You can reach me on my cell phone, by e-mail, or by texting. I am looking forward to working
with you to achieve your exercise goals.
Sincerely,
Sam Spencer, B.S. CPT
Personal Trainer, ExerClub
Cell (Voice and Text): 212-444-4444
E-mail: SSpencer@ExerClub.com
Mr. Jones responds to Sam’s e-mail with a text asking him to call on Thursday at 8am. Sam replies by
text:
Mr. Jones-Will call you Thurs. March 7 @ 8am @ 212-666-6666. Let me know if another number
is better. Sam Spencer, ExerClub
Sam calls Mr. Jones at the appointed time:
Hello, Mr. Jones. This is Sam Spencer, the personal trainer at ExerClub. Is this time still okay to
talk? Great! I am calling today to learn a little more about you so I can help you achieve your exercise
goals. This will take about five minutes. Does this fit with your schedule today? Okay, great! Can you
tell me a little about why you decided to start exercising?…I see…You have noticed you are often
tired and you would like to increase your stamina. An exercise program can often help people feel
more energetic. With most of my clients, we meet once or twice per week for 30–45 minutes to start,
but we can meet more or less frequently depending on your preferences. I imagine you have a very
busy schedule, so what do you think will work for you?…Twice per week sounds like a reasonable
place to start—we can always revise this as needed.
To get started, we will need to schedule a visit to get more information about your health, exercise
preferences, and to do some tests to evaluate your fitness so I can recommend a program that best fits
your needs. After that, we can set up your training sessions. This first visit will take about 1 hour.
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Would you like to schedule that now?…Okay, how about Tues March 12 at 7am? Perfect! In the
meantime, there are some information forms I can send you to fill out to save time during your visit. I
can send them in the mail or by e-mail. Which do you prefer?… Okay, I will send them in the mail…
Let me confirm your address…Thank you, Mr. Jones.
I look forward to meeting you on March 15 at 7am at ExerClub at Broadway and East 57th Street
in Manhattan. I will send an electronic calendar request to your e-mail so you can easily put this into
your calendar. I will also text or e-mail a reminder the day before. Do you have a preference? Okay, I
will text you a reminder. Do you have any questions?…Thanks for your time, Mr. Jones…Goodbye.
It is important to remember that e-mails are generally not encrypted and are not secure. Employers and
other individuals can access information sent via e-mail, text, or electronic chat, therefore these modes of
communications are not appropriate for discussing or collecting personal and sensitive information. The
practitioner and client must understand this limitation. The use of social networks, Web sites, chat rooms,
videoconferencing, and blogs can be a valuable platform for exchanging information and ideas with clients or
other professionals. These modes can be helpful in monitoring progress, problem solving, providing social
support, and as a resource for general educational material about exercise and health topics, highlighting
special events and resources for physical activity, program schedules, and the like.
TEACHING AND LEARNING
The practice context of the health and fitness professional involves the use of various behavioral and teaching
strategies that are individualized to meet the client’s learning style and personal preferences. To be effective,
behavior change and learning theories should form the basis of the instructional methods and behavioral
strategies employed. Effective teaching involves the combination of demonstration, visual observation, verbal
explanations, and feedback (Figure 10.1). One of the most common forms of instruction involves the
instructor demonstrating and explaining an exercise, followed by the client performing the exercise while the
instructor observes and provides feedback. Table 10.1 provides some tips for teaching an exercise.
TABLE 10.1 Points Included in Teaching an Exercise
Introduce the exercise using a simple name.
Explain why the exercise is part of the program (i.e., its benefits).
Compare the exercise to a familiar activity or an easy action verb.

Example: “The first exercise we are beginning with today is a stationary lunge. This exercise is great for strengthening the muscles of the
hip and the knee. You can think of this exercise as being like the squats we did on Monday, but this time our legs are staggered in front
of each other instead of being next to each other so that the forward leg is doing the majority of the work.”
Cue the exercise using as few words as possible, while demonstrating it so the client is receiving both verbal and visual cues. The key to
effective cueing (without over-cueing) is using concise action words that are easy to follow.
Demonstrate the exercise while making eye contact.
Highlight any moves that you want them to think about by using action verbs or metaphors—it is always more effective to tell them what to
do as opposed to what not to do.
Example: While demonstrating the exercise, and using fingers to point to the areas that are being referred to, “As you can see, the
forward foot is completely on the ground, hips are level, spine should remain tall reaching to the top of the head, and shoulders are
squared toward the front. While maintaining a tall spine, begin by lowering the hips to the ground and then pushing back up. You can
adjust your feet as necessary to make you feel more stable.”
©Kimberly S. Perez, 2011. Used with permission.
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FIGURE 10.1. Components of teaching physical activities and exercise. (© Carol Ewing Garber, Ph.D., 2012. Used with permission.)
THE ENVIRONMENT
To facilitate physical activity behavior change, the physical environment in which counseling, testing, and
training takes place should be pleasant, safe, and comfortable. This can be easily accomplished by maintaining
a neat and clean facility that is free of clutter and physical hazards. For evaluation and counseling sessions, it is
important that there is privacy and that the area is free from distractions. There may be a need for a noise
canceling device to minimize the possibility of transfer of sensitive and personal information to others.
Appropriate accommodations for persons with disability are made, to ensure accessibility of services to all.
STEP-BY-STEP: Preparation and Follow-Up for Client Sessions
Being fully prepared for each encounter with a client—whether an intake, counseling, testing, or training
session—is imperative, and will go a long way in facilitating the client’s behavioral change and attainment of
personal goals. With a busy schedule, it is often easy to underestimate the time needed for preparation, rely on
previous experiences, or provide “cookie cutter” sessions for all clients, but this will not yield optimal results.
Tailoring exercise counseling and training sessions based on the individual’s characteristics is an effective
strategy in facilitating physical activity behavior change (2). In addition, being unprepared can result in serious
errors that could jeopardize client health or safety.
Thorough preparation for a session includes a review of the client’s available records, such as current and
past medical history and physical activity behavior and performance during previous training sessions. The
review allows the health and fitness professional to thoughtfully consider how to approach the client, ensure
that the session is tailored appropriately to the client’s needs and readiness to change physical activity, and to
maximize safety. Incorporating current information from credible sources is key for effective professional
practice. However, being aware of recent news or magazine articles about exercise and being able to discuss
these with the client can provide excellent opportunities for dialog and education.
Whenever possible, it is important to coordinate efforts with other health professionals such as the primary
care physician, physical therapist, or dietician who may be working with the client. This helps ensure that all
will be providing consistent advice and coordinated services, which will maximize the benefits to the client
and reduce confusion that may interfere with behavior change. Each of these things can be done well before
the client comes to his or her visit with the health and fitness professional, with prompt follow-up after the
client’s visit as needed.
STEP-BY-STEP: Exercise Programming and Testing
Components of a Physical Activity Counseling Session

A physical activity counseling session is best conducted with open-ended questions designed to engage the
223
client and health and fitness professional in an open dialogue. This fosters a highly interactive environment
for developing the individualized physical activity program. The open-ended approach encourages the client
to reveal true feelings, concerns, and relevant information because it helps to develop a “safe space” where the
client feels comfortable and may be more willing to share personal information. There are many theoretical
frameworks that can be applied to the counseling session, and the health and fitness professional is advised to
develop one that fits the environment, time constraints, and clientele. However, there are elements that are
commonly incorporated into every counseling session, depending on the theoretical model being applied.
These include:
1. Clearly stating the purpose of the session
2. Assessment of the client’s readiness to change behavior
3. Providing specific recommendations or advice to the client based on their responses, health status,
sociodemographic considerations, environment, and physical activity goals
4. Summarizing the plans developed and ensuring client understanding
5. Setting up a time line and mode for following up (see Figure 10.2)
The most information is often obtained from the client by asking open-ended questions, but there is a place
for polar (i.e., “yes or no” questions) and objective questions, which are more specific in the responses
expected. Table 10.2 presents a framework for asking effective questions.
Try to learn as much as you can from the client. This is an opportunity to create an open dialogue, set the
framework for future meetings, and assist in developing an individualized program. In asking effective open-
ended questions during the counseling session, the practitioner is using the client-centered skill of
motivational interviewing. Motivational interviewing allows for two major achievements: one for the
practitioner and the other for the client. For the practitioner, allowing the client to speak freely about their
barriers, concerns, fears, likes, dislikes, etc., will provide much insight into the client’s preferences, personality,
and relapse risks, and it will facilitate the development of an individualized program. In other words, the
health and fitness professional can utilize that information to develop an effective program that the client will
enjoy and to which they may be able to adhere. The major achievement for the client is that they can make
personal discoveries about their lifestyle, which further allows the client to develop tools and strategies to
successfully manage a physical activity program. This interactive process also promotes a sense of shared
teamwork and support to achieve the client’s goals. Remember, this does not happen after one session; this
give-and-take discussion is an ongoing process. It takes work, time, and patience to make lifestyle and
behavior changes. Plans and approaches often need to be modified due to changing circumstances,
experiences, and attitudes.
FIGURE 10.2. Typical elements of a counseling session. (© Carol Ewing Garber, Ph.D., 2012. Used with permission.)
TABLE 10.2 Generating Effective Questions
Polar Question Objective Question Open-Ended Question
Do you enjoy exercising? When you exercise would you say you prefer high- What are some of the high-intensity activities
intensity activities or moderate-intensity activities? you enjoy doing?
Do you smoke or have Around what time last year did you quit smoking? That is great that you have not smoked in over
you quit smoking within 10 months. What changes have you noticed since
the last year? you stopped?
Are you interested in What would you describe your ideal weight to be? In What factors do you feel may have contributed to
gaining or losing weight? other words, what weight do you think will make you your weight gain?
feel comfortable?
© Kimberly S. Perez, 2011. Used with permission.

Note: Questions asked during the initial interview are often done as a follow-up to preparticipation paperwork that has previously been
administered, thus using polar questions may be repetitious and unnecessary. Notice that open-ended questions often begin with a paraphrase of
the response to the previous objective question.
Review of Health Status
224
As recommended by ACSM, a thorough review of health status is important as part of the initial intake of the
client, with updates being part of regular visits. The reader is referred to Chapter 2 and the American College of
Sports Medicine Guidelines for more information and tools for this purpose (1). Health information is
important not only for client safety, but also to tailor the physical activity program to accommodate
limitations imposed by an acute or chronic health condition.
REVIEW OF PHYSICAL ACTIVITY AND EXERCISE BEHAVIOR
Understanding the client’s current and past physical activity behavior is crucial when formulating a new or
revised program of exercise, as noted in Chapter 2. There are many available physical activity questionnaires
or tools such as pedometers that can be used to assess and monitor physical activity and exercise behavior.
From a behavioral standpoint, learning about the individual’s perceptions and attitudes about previous,
current, and future experiences is key to facilitating physical activity behavior change. Also of importance is
the understanding of other cognitive, social, environmental, and psychological factors that can affect exercise
preferences and behavior, such as self-efficacy, cultural norms, and neighborhood environment. While
somewhat time consuming, a thorough understanding of these individual, social, and environmental factors
will help the health and fitness professional develop an exercise program that is uniquely tailored to the
individual, and increase the likelihood of adoption and adherence to exercise and physical activity. Table 10.3
presents tips for conducting a screening and initial counseling session.
TABLE 10.3 Tips for the Physical Activity Intake/Screening Session
Greet the client. Call the person “Mr./Ms. ___________.” Then ask the client by what name they want to be called. This shows respect for
the client and also helps confirm that you are speaking with the correct person.
Introduce yourself.
Example: “I am John, the Exercise Physiologist at the Excel Fitness Center.”
Introduce the purpose of today’s visit.

Example: “I am a certified personal trainer, and today I want to learn more about you so I can provide the best program for you.”
Try to make the client feel comfortable. Sit at the same level or lower than the client—never stand or sit towering over the person.
Sit in a way that welcomes conversation. Make eye contact, lean forward, look interested in the client.
Speak clearly and slowly, and look at the client to see if they understand. Consider that the client may have a hearing or language difference
that they are reluctant to reveal to you.
Use open-ended questions to start out.

Examples:
“How are you feeling today?”
“Can you tell me why you are here today?”
“Have you done any exercise before?”
Clarify and get more information. Clarify any answers that you don’t understand or may be conflicting with other statements/information
the client has given you. Ask for more detail about something that might be important (i.e., chest discomfort).
Use reflective responses that repeat what the client said.

Example: “You mentioned that you have some pain in your right knee. Can you tell me more about that? What does it feel like? When
does it hurt?”
Validate concerns that the client mentions.

Examples:
“It is intimidating to come to a fitness center for the first time.”
“You seem worried that you will have trouble exercising because you aren’t athletic.”
Ask the client what they think the problem is concerning their health or fitness.
Examples:
“What do you think about your exercise habits right now?”
“What is your major health issue?”
Respond appropriately if the client avoids talking about something or seems anxious or uncomfortable about something.
Examples:
“Many people are worried about going to the gym because they are worried about their appearance.”
“Many people are afraid to go to the gym because they might not know what to do. Has this happened to you?”
225
Sum up your take of what the client has told you.
Example: “Mr. Jones, I want to make sure that I understand correctly what you have told me…[repeat what they have said in your own
words].”
Ask specific questions about the client’s current and past health—relevant to your client’s needs and fitness setting. Complete details on
health screening are found in reference (1) (American College of Sports Medicine, 2013).
Example: “Now Mr./Ms. Jones, I need to ask you a few questions about your health, because your health can affect the types of exercise
you can do safely.”
The information to be gathered generally includes:

• History of current illness
• Past medical history
• Current medications (name, dose, purpose)—include over-the-counter medications and vitamins
• Allergies
• Risk factors for cardiovascular disease
• Alcohol or drug use
• Symptoms of angina pectoris, claudication, shortness of breath
• Any discomfort/pain related to exertion
• Sleep habits
• Psychosocial (e.g., living situation, occupational status, education)
Ask directly if you want to know something. Clients often expect you to uncover problems and won’t necessarily volunteer information.
Ask the client if there is anything that they are concerned about.
Example: “Is there anything we have not discussed that you would like to talk about?”
Ask the client if they have any questions.
End by summarizing the session, thanking the client, and letting the client know what to expect next.
© Carol Ewing Garber, Ph.D., 2010. Used with permission.
Constantly repeat yourself while working with clients; one never knows whether the information relayed is
being understood or if the client is attending to your message. For example, a client may not remember an
instruction to keep their forward knee above their foot while performing a static lunge, or that a stretch should
be held for 10–30 seconds.
A professional and nonjudgmental approach is helpful when inquiring about current and past exercise
behavior. This helps maintain open lines of communication, allows for more frank dialogue between the
professional and the client, and increases the likelihood that the client will feel comfortable in truthfully
revealing their behavior and feelings about their exercise experiences, and—most importantly for continued
exercise—they will continue to keep their appointments and return e-mails and phone calls. This openness
will help the health and fitness professional and the client work through problems and barriers that are
encountered by the client in their quest to be a regular exerciser. It is helpful for the health and fitness
professional to be accepting that not all people like to exercise, and that many find exercise to be difficult or
unpleasant and have concerns about their abilities to be physically active.
When obtaining a physical activity history, first explain what is meant by physical activity and exercise, as
the client may lack a clear and comprehensive understanding. An inventory of all physical activity behavior,
including activities of daily living, occupational and transportation physical activities, and exercise, is helpful
because it gives information that will assist in fitness assessments and exercise prescription, but it may also
offer clues as to an approach to take in developing a program. For example, if someone says they “hate to
exercise” but “love to dance,” consider suggesting a program that involves dance-like activities. In addition to
learning about what and where exercise is being done—or has been done in the past—ask specifically about
the client’s exercise likes and dislikes.
Understanding these likes and dislikes will help in developing a program that is pleasant and enjoyable as
possible for the client, improving the likelihood of exercise adoption and adherence. Knowledge about
previous injuries and physical activity limitations is also helpful from both the health and behavioral
perspective. For example, if someone had a previous knee injury, exercises that may aggravate the injury and
cause pain can be avoided. On the other hand, exercising painful arthritic joints may be beneficial, so the
client will need to be instructed about when and how to exercise through pain and when pain signals to them
“stop exercising.” Educate clients to be aware of the need to push themselves, while at the same time
recognizing their limits. Since painful or unpleasant exercise reduces enjoyment, it will also be important to
identify markers of improvement so the client can monitor the benefits of exercise, even if there may be some
discomfort associated with it.
The social, occupational, and cultural environment of the client is also important from a behavior change
perspective. Asking questions about occupation, living situation, and community are helpful in tailoring the
226
program to the individual, and increasing the likelihood of their being able to start and maintain a regular
program of physical activity. For example, the busy executive may have significant time limitations or
limitations imposed by frequent travel, while the parents of young children may have to obtain childcare so
they can exercise. Some religious and cultural groups may prohibit co-ed exercise situations, or may mandate
dress that may make some types of exercise difficult. Some cultural groups may not be supportive of exercise
or certain types of exercise, and this can vary by gender. Perceived neighborhood safety, community exercise
resources, and climate are also considerations. Addressing these barriers to exercise can help ensure the
development of an exercise program that the individual is able to do on a regular basis.
The development of an exercise program should be highly interactive, with active involvement of the client
in the process to ensure buy-in and commitment and a program that best meets their needs and preferences.
Before implementing the program, re-check with the client to see that it seems reasonable to them and it is
consistent with their wishes. As part of the process, plan for potential barriers that may arise and address the
probability of regression (missing sessions, not adhering to the program), and emphasize that the plan is a
guide that can be adjusted as needed.
Counseling for Follow-up Testing and Referrals

If problems arise, it may be necessary to consider referrals to health care professionals for further evaluation or
treatment before starting or resuming exercise. While the need for medical clearance or medical treatment can
present a barrier for starting or changing an exercise program, this should be done as indicated according to
American College of Sports Medicine Guidelines (1). The health and fitness professional can provide an easy-to-
use form that clearly and concisely outlines the health concern and the specific questions that the health and
fitness professional wants to be addressed. This can help the physician or other health professional to quickly
and easily respond during the office visit. It is important to avoid unduly alarming the client when a potential
health issue is uncovered, but at the same time the seriousness of the situation should be made clear. For
example, if during the visit, the client’s blood pressure is elevated on multiple measurements, mention this
matter-of-factly to the client, without minimizing the import of the problem—e.g., “Ms. Smith, your blood
pressure seems a bit high today. Have you ever been told your blood pressure is high before? It may just be
that you are in an unfamiliar situation, which can raise your blood pressure, but I think it would be a good
idea to follow up with your doctor, just to be sure. I can fax this information to your doctor and you can follow
up with a phone call, or, if you prefer, I can write down your blood pressure readings and you can make an
appointment with your doctor.”
When conducting fitness tests, make sure to explain fully to the client what the tests are and why they are
being done. This is part of the consent process, which should go well beyond providing the client with a piece
of paper and asking them to sign it. Rather, a full verbal explanation of the tests, risks, benefits, and
alternatives to testing should be given, followed by an opportunity for the client to ask and have answers
provided to all questions. It is important to ensure that the client understands that they may decline to take
any of the tests, or to stop testing at any time. If any of the tests are mandatory according to the fitness center
policy, this should be clearly communicated as well.
The Exercise Training Session

During the exercise training session, the focus is on teaching exercise skills and techniques and monitoring the
client during exercise. What is unique about the health and fitness professional’s role is the power to influence
and heighten the sense of accomplishment by teaching and providing feedback. Verbal and nonverbal
communication techniques are employed during exercise training sessions to motivate and encourage the
client. During the initial phases of an exercise program, what motivates a person to return may be the hope of
experiencing benefits and a sense of accomplishment from completing the exercises. Later on, the client may
notice physical and mental changes such as better fitting clothing and feeling more energetic, and these
provide further positive reinforcements. The health and fitness professional can assist the client in becoming
more aware of their body and being able to notice subtle changes more readily. Incorporating self-monitoring
data collection methods to demonstrate accomplishment or improvement such as logs, accumulation of
distances or time, pedometer counts and other self-monitoring devices, and apps or online tools can also be
helpful and effective monitoring methods that can facilitate physical activity behavior change (2).
Take-Home message
227
The health and fitness professional can do much to promote and facilitate physical activity behavior
change in a client. Professional appearance, behavior, and communications of the health and fitness
professional are keys to success, as is maintaining high standards of professional practice that is current
and up to date. Employing teaching and health behavior change techniques based on theoretical
constructs enhances client behavior change and physical activity adoption and adherence. Ethical
considerations such as confidentiality and adhering to professional ethical standards are inherent in the
practice of the health and fitness professional. In addition, cultural sensitivity, avoiding potentially
derogatory speech and behaviors, and respectful and appropriate touching are also integral to the
practice of the health and fitness professional.
REFERENCES
1. American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 9th ed. Philadelphia (PA): Lippincott
Williams & Wilkins; 2014.
2. Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory,
musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc.
2011;43(7):1334–59.
3. Marcus BH, Williams DM, Dubbert PM, et al. Physical activity intervention studies: What we know and what we need to know: A
scientific statement from the American Heart Association Council on nutrition, physical activity, and metabolism (Subcommittee on
Physical Activity); Council on Cardiovascular Disease in the Young; and the Interdisciplinary Working Group on Quality of Care and
Outcomes Research. Circulation. 2006;114(24):2739–52.
4. Seguin RA, Economos CD, Palombo R, Hyatt R, Kuder J, Nelson ME. Strength training and older women: A cross-sectional study
examining factors related to exercise adherence. J Aging Phys Act. 2010;18(2):201–18.
228
Index
Note: Page numbers followed by f indicate figures; those followed by t indicate tables.
A
Accelerometers, 46, 177–178, 179–180t
ACSM guidelines
exercise prescription for cancer survivors, 227–228t
preexercise medical assessments and exercise testing, 226t
review of US DHHS PAG for Americans and alterations needed for cancer survivors, 229–231t
Action. See also Action stage
cues to, 33
planning, 63–64, 78, 91, 195
reflections, 136, 144
taking, 33, 194, 195
translating intentions into, 89–94
Action stage
goal in, 117
individuals in, 59, 105
key intervention strategies, 117, 119
and Maintenance stage, 15, 16
processes of change, 108t
sample activity, 118
as TTM stage, 11, 105
Active living, 198, 199t
“Activity friendly”, 194t
Adoption (in RE-AIM), 240t
planning for
evidence, 247–249, 247t
RE-AIM step-by-step evaluation, 252–253
program development questions, 239f
Adoption and maintenance, 104, 147, 197
Advise (5 A’s model), 139
Advocate, definition of, 193t
Aerobic activity, 54, 208t, 216t, 229t
Aesthetics, definition of, 193t
Agree (5 A’s model), 139
AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire, 48, 51f
Alcohol consumption stage, 67
Amotivation, 19, 132
Amplified negative reflections, 135
Anterior cruciate ligament (ACL), 8
Application Programming Interface (API), 183
Arrange (5 A’s model), 139
Ask (5 A’s model), 139
Assess (willingness to change) (5 A’s model), 139
Assist (5 A’s model), 139
Athlinks, 171t
Attitude, 24–25, 84–85
Automaticity, 92–93
229
Autonomy, 20, 134, 149
B
Baecke Questionnaire (BAECKE), 55t
Balance, decisional. See Decisional balance
Balance exercises, 216t
Balanced diet stage, 66
Barriers
efficacy, 6
to PA participation, 212
among older adults, 215
for overweight and obese individuals, 223t
Behavior
assessment of physical activity, 43t
defined, 2
exclusions, 136
and intentions, 72, 77, 80, 83t, 84f
interrelations between different domains, 66f
motivation and, of individuals, 60f
suggestions, 136
Behavior change. See also Children and youth; Communication skills; Older adults; Transtheoretical model
(TTM) of behavior change; RE-AIM framework
Health Belief Model (HBM), 33
principles of, 2–4
reasons for, 2
reinforcement for, 3
strategies, 3–4
relapse prevention, 33
resources for clients, 124
self-determination theory, 18–24
self-efficacy theory, 5–9
setting, 193t
Social Ecological Model, 34–35, 34t
stages of, 61–62
theories and models, importance of, 4–5
theory of planned behavior, 24–32
Behavioral antecedents, 35
Behavioral counseling
link between policy, environments, and individual PA programs and, 195f
WHO and U.S. guidelines for PA, 196t
Behavioral palate worksheet, 73–74, 86
Bone strengthening, 208t
C
Cancer survivors
ACSM guidelines for PA levels for
barriers, 225
evidence, 222–225
exercise prescription for cancer survivors, 227–228t
preexercise medical assessments and exercise testing, 226t
recommendations, 225
review of US DHHS PAG for Americans and alterations needed for cancer survivors, 229–231t
PA interventions for, 232t
PA role for, 222
Cardiovascular disease, 222
individuals and populations with, 224t
Children and youth
230
promoting PA behavior change in, 207
adherence and maintenance considerations, 212–213, 212t
barriers, 212
evidence, 207
implementing programs, 209t
interventions, 210t
recommendations, 207, 208t
Choose phase, 144
Chronic conditions
adherence and maintenance considerations, 221
cancer survivors, role of PA for, 222
barriers, 225
evidence, 222–225
recommendations, 225
cardiovascular disease, 222
overview of, 221
overweight and obesity, 221–222
Chronic Contemplation, 105
Client-centered approaches, 138
5 A’s model (ask, advise, assess, assist, arrange), 138–139
evidence for
motivational interviewing and physical activity, 146–147
self-determination theory and physical activity, 147–148
tailoring and cultural considerations, 148–149
relationship among MI, SDT, and 5 A’s, 139–140
three-phase model (Explore, Guide, Choose), 143–144
Client-centered counseling, 134, 137
Client sessions, preparation and follow-up for, 268
Clinical counseling and community practice vignettes, 199
Cognitive suggestions, 136
Commercial integrated intervention systems, 182–183
Communication skills, 129
client-centered approaches, 138
alternative approach, 143
traditional approach, 138
eliciting change talk, 137
intermediate/advanced training, 138
introductory training, 138
motivational interviewing, 131
and physical activity, 146–147
reflective listening, 134–137
self-determination theory, 132
autonomy, 134
competence, 133–134
continuum of motivation, 132–133, 132f
relatedness, 134
tailoring and cultural considerations, 148–149
Communications
with first-time client, 265–266
S-M-C-R model of, 154
telephone and electronic, 265, 267
verbal and nonverbal, 264–265
Community-based physical activity programs, 243, 244
Competence, 19, 21, 133–134
Computer-generated print media, 156–159
Computer mediated communication (CMC), 154
231
Consciousness raising, 11, 107t
Contemplation stage
goal in, 112
key intervention strategies, 112
processes of change, 108f
Content reflections, 135
Coping planning, 63–64, 91
Coping strategies, 33
Counseling session, PA
components of, 269–270
effective questions, 270t
for follow-up testing and referrals, 273–274
typical elements of, 269f
Counterconditioning, 11, 15, 107t
Cross-behavioral conflict, reduction of, 93–94
Cues to action, 33
D
Data sharing, across systems and technologies, 183–184
Decisional balance, 11, 84–85
scale, 17
in stages of change, 106
worksheet, 75, 85
Dietary and eating habits, 66–67
Direct physical activity measures, 246t
Discrepancies, developing, 137–138
Dlife For Your Diabetes Life!, 171t
Double-sided reflections, 135
Dramatic relief, 11, 107t
E
E-mail, 265, 267
Eating and dietary habits, 66–67, 147
Ecological model, of physical activity, 40–41 40–41f
Effectiveness (in RE-AIM), 240t
evidence, 245–247
Efficacy, 245. See also Effectiveness
Electronic communication, 265, 267
Electronic technologies, as communication channels, 154
computer-generated print media, 156–159
interactive voice response (IVR) systems, evidence for, 161–163
Internet interventions, evidence for, 160–161
multiple channels, integrating across, 181
commercially available integrated intervention systems, 182–183
data sharing, 183–184
smartphones, 181–182
physical activity monitoring devices, 176
accelerometers, 177–178
global positioning systems (GPS), 178–179, 179–180t
heart rate monitors, 178
pedometers, 177
S-M-C-R-F model, 154–155
S-M-C-R model, 154
232
social media, 170
evidence, 171
Facebook, 172–173
social network growth, 173–176
Twitter, 173
steps in developing electronic media intervention, 162t
text messaging, 163, 166t
evidence, 164–165
limitations, 169–170
Elicit-provide-elicit framework, 140
Eliciting change talk, 137
developing discrepancy, 137–138
measuring importance and confidence, 137
Emotional (mood) states, 6, 8
Empowerment, 170
Environment, physical, 268
Environmental reevaluation, 11, 107t
Environmental support for exercise, 93
Events (Facebook), 172–173
Exercise
behavior, 270–274
contract, 81
defined, 2
efficacy, 6
expected outcomes of, 84
perceptions of control over, 87
programming and testing, 269–270
social influences on, 234
test, 52f
training session, 274
Exercise is Medicine, 238
Exosystem, 35
Expected outcomes
benefits of regular activity, 85
changing and improving, 84–86
focusing on environment, 86
toward physical activity, 84
Explore phase, 143
External regulation, 19
Extrinsic motivation, 19, 132
Eye contact, 264
F
Facebook, 170, 171t, 182
events, 172–173
groups, 172, 174f
for many-to-many delivery, 155
Marketplace application, 173
networks, 172–173
newsfeeds, 173
pages, 172
Feedback, self-monitoring and, 92
Feeling/meaning reflections, 135
Fitness testing, 212
FitBit, 182–183
5 A’s model, 138–139
Flexibility, 216t
233
Fruit and vegetable consumption stage, 66
G
Global positioning systems (GPS), 46, 178–179, 179–180t
Goal setting
and planning, 90–91
worksheet, 76–77
Godin Leisure-Time Exercise Questionnaire (GLTEQ), 55t
Groups (Facebook), 172, 174f
Guide phase, 144
Gymnasium, 41
H
Habituation, 58
Handshaking, 264
Health
behaviors, 43, 65
and fitness professionals, 264–274
identifying risk factors, of exercising for individual, 48
objective measures to assessing, 53t
status, review of, 270
Health Action Process Approach (HAPA) stages, 60t
Health-behavior efficacy, 6
Health Belief Model (HBM), 33
Health History Questionnaire (HHQ), 48, 53–54
Health-promoting lifestyle profile II (HPLP II), 66
Health Risk Appraisal (HRA), 48
Healthy drinking stage, 66
Heart rate monitors, 178, 179–180t
Hello Health, 171t
Helping relationships, 11, 107t
Human computer interaction (HCI), 154–155
I
IDEA approach, 91
Identified regulation, 19, 133
Implementation (in RE-AIM), 241t
evidence, 249–251, 250t
RE-AIM step-by-step evaluation, 254
Individuals’ PA and motivations
assessment modes, 43
advantages and disadvantages of, 44t
behavior assessment, different aspects of, 43t
concept overview, 42
ecological frameworks, 40–41, 40f
guidelines, 40
objective measures, 46
examples of, 46t
self-reported information, 43–46
step-by-step method for determining, 41
Informed consent, 49
sample form for exercise test, 52f
Integrated intervention system, 182–183
Integrated regulation, 19
Intention-behavior gap, 72, 77, 80, 83t, 84f
Intentions, 24, 59
234
behavior and, 72, 77, 80, 83t, 84f
building initial, 80, 84
expected outcomes of exercise, 84–87
implementation, 93
perceptions of control over exercise, 87–88
translation of, into behavior
environmental support for exercise, 93
goal setting and planning, 90–91
partial automaticity of the act, 92–93
reduction of cross-behavioral conflict, 93–94
self-monitoring and feedback, 92
self-regulatory skills, 89–90
Interactive voice response (IVR) systems, 159, 161
evidence for, 161–163
Intermediate/advanced training, 138
International Physical Activity Questionnaire (IPAQ), 55t
Internet interventions, evidence for, 160–161
Intrinsic motivation, 20, 132
Introductory training, 138
Introjected regulation, 19, 133
L
Likert scale, 57, 62
Linked In, 171t
M
Macro-level policy or environment, definition of, 193t
Macrosystem, 35
Maintenance (in RE-AIM)
evidence, 251–252
step-by-step evaluation, 255–256
Maintenance stage, 241t
avoiding boredom, 121
goal in, 119
sample form for monitoring workouts to, 122
strategies to, 121, 123
RE-AIM program development questions, 239f
sample activity, 120–121
Marketplace application (Facebook), 173
Mastery (performance) experience, 5, 7, 88
Mesosystem, 35
Messages. See Electronic technologies, as communication channels; Print media, computer-generated
Microelectromechanical systems (MEMS), 176
Microsystem, 34
Mixed use, definition of, 193t
Models and theories, importance of, 4–5
Moderate-intensity activity, defined, 206
Moderate-intensity cardiorespiratory exercise, 40
Mood states, 6, 8
Motivation
and behavior of individuals in different stages, 60t
continuum of, 132–133, 132f
and intention, 59
to performing PA, 58
235
stage of change, 59–61
types of, 19–20
Motivational interviewing (MI), 130, 131, 139–140, 146–147, 269
My Space, 170, 171t
N
Negative emotional states, 34
Negative energy balance, definition of, 193t
Networks (Facebook), 172–173
Neuromotor exercise, 40
Newsfeeds (Facebook), 173
Nonintentional stage, 61–62
Nonverbal communication, 264
O
Obesity, overweight and, 221–222
PA recommendations and considerations for, 223
Objective measures
to assessing health, 53t
to assessing PA level and physical fitness, 46t
subjective assessment and, 44t
Observational learning, 5
Older adults
adherence and maintenance considerations, 215, 219t
barriers, 215
evidence, 215
implementing PA programs, 217-218t
interventions, 219t
Outcome expectancies, 62–63
Overweight and obesity, 221–222
PA recommendations and considerations for, 223t
P
Pages (Facebook), 172
PARmed-X, 49
for Pregnancy, 49
Pedometers, 44, 46, 177, 179–180t, 193t, 270
Perceived barriers, 33
Perceived behavioral control, 25, 87
Perceived benefits, 33
Perceived severity, 33
Perceived susceptibility, 33
Personal conflict, 34
Personal digital assistants (PDAs), 181
Physical activity (PA)
assessment of, 54–55
behavior assessment, 43t
changing and improving expected outcomes, 84–86
control perceptions of, 87–88
counseling session
components of, 269–270
effective questions, 270t
typical elements of, 269f
domains and components of, 56–58, 56t
ecological model of, 41f
236
and exercise behavior, 270
counseling for follow-up testing and referrals, 273–274
exercise training session, 274
tips for conducting screening and initial counseling session, 271–272t
and exercise environments, 86
expected outcome of exercise, 84
intensity, 56t, 193t
levels of, 56
measures, 55t
monitoring devices, 179-180t
accelerometers, 177–178
global positioning systems (GPS), 178–179
heart rate monitors, 178
pedometers, 177
practical questions, 40f
recommendations for weight loss and prevention of weight gain, 55t
regular activity benefits, 85
techniques for adherence/maintenance, 212–213, 212t, 222t
using physical environment to promoting, 198–199
vigorous, 193t
Physical activity behaviors
behavior change
principles of, 2–4
theories of, 4–35
defined, 2
incorporating theory-based techniques
and principles into practice, 35–36
reasons for changing, 2
self-determination theory in, 18–24
self-efficacy theory in, 7–8, 7f
theory of planned behavior, 24–32
transtheoretical model in, 12–17
Physical activity policy
as defined guidelines, 194–196
as set of written rules or regulations, 192–194
as unwritten social norms, 196–197
Physical Activity Readiness Questionnaire (PAR-Q), 44, 53
AHA/ACSM Health Fitness Facility Pre-participation Screening, 49, 51f
informed consent, 49, 52f
PAR-Q and YOU, 49, 50f
PARmed-X, 49
PARmed-X for Pregnancy, 49
screening for exercise preparedness, 49
Physical exercise programs, 41
Physiological state, 6, 8, 88
Planning
types of, 90–91
worksheet, 78–80
Policy, PA
as defined guidelines, 194–196
and practice, links between, 198
as set of written rules or regulations, 192–194
as unwritten social norms, 196–197
Precontemplation stage
goal in, 109
237
as TTM stage, 10–11, 104–105
Preparation stage
goal in, 114
Print-based tailored intervention, developing, 158t
Print media, computer-generated, 156–159
Processes of change, 11–12, 106–107, 107t
scale, 14–15
by stage, 108f
Psychological needs, 133
autonomy, 134
relatedness, 134
Q
Quality of life measures, 246t, 251
R
RE-AIM framework
Adoption, planning for
evidence, 247–249, 247t
definitions, data requirements, and example study and outcomes, 240–241t
Effectiveness
evidence, 245–247
Implementation
evidence, 249–251, 250t
step-by-step evaluation, 254
Maintenance
evidence, 251–252
and program development questions, 239f
Reach
evidence, 242–244
Reach (in RE-AIM), 240t
evidence, 242–244
Readiness to change
assessing, 108
defined, 58
target interventions to individual’s, 108
Reflection on omission, 135–136
Reflective listening, 134
action reflections, 136
amplified negative reflections, 135
content reflections, 135
double-sided reflections, 135
feeling/meaning reflections, 135
reflection on omission, 135–136
rolling with resistance, 136–137
238
Reinforcement
management, 11, 107t
principles of, 3
strategies, 3–4
Relapse prevention, 33, 123
strategies to avoiding, 123–124
Relatedness, 19, 134
Representativeness, determining, 244t
Residential density, definition of, 193t
Resistance
rolling with, 136–137
training, 40, 56t, 229t
Rewards, 3
Risk perception, 62
S-M-C-R-F model, 154–155

S-M-C-R model, 154
Scheduling efficacy, 6
Self-determination theory (SDT), 12f
basic psychological needs, 133
autonomy, 134
relatedness, 134
concept overview, 19–20
continuum of motivation, 132–133, 132f
evidence, 20
goal setting and, 22
motivation, types of, 19–20
and motivational interviewing (MI), 130
and 5 A’s, 139–140
techniques and strategies, 134–138
training, 138
step-by-step description
applying to physical activity behaviors, 20–21
Self-efficacy theory
aspects of, 6
evidence, 6–7
for exercise, 15
and Health Belief Model, 33
motivational self-efficacy, 63
and perceived behavioral control, 87
scale, 16
sources of, 5–7, 7f, 87
in stages of change, 106
and transtheoretical model, 12
volitional self-efficacy, 57, 63
Self-liberation, 11, 107t
Self-monitoring
and feedback, 92
worksheet, 82
Self-reevaluation, 11, 107t
239
Self-regulatory skills, 89–90
Self-reported information
precision of measurement, 45–46
time considerations, 44–45
tools for assessing, 43–46
Self-reported physical activity measures, 246t
Shaping, 4, 88
Short-messaging services (SMS), 163
Short-term intervention programs, 160
Skype, 154
SMART goals, 76–77, 90
Smartphones, 181–182
Smoking behavior, 67
Social Cognitive Theory, 80, 89
Social desirability bias, 44
Social Ecological Model, 34–35, 34f
Social liberation, 11, 107t
Social media, 170
evidence, 171
Facebook, 172–173
social network growth, 173–176
Twitter, 173
Social modeling, 87, 88
Social networking sites
cautions when using, 176
developing, 173–176
integrating, 182
popularity of, 170–171, 171t
Social pressures, 34
Social support, 62, 64
environmental support for exercise, 93
Socio-ecologic models, 194t
Sprawl, definition of, 193t
Stages of change model, 10–11, 10f, 104–105, 105f. See also Transtheoretical model (TTM) of behavior
change
Action stage, 11, 105
assessments, 45t
Contemplation stage, 11, 105
individuals in moving forward in
decisional balance, pros and cons, 106
processes of change, 106–108, 108f
readiness to change, 108
self-efficacy, 106
Maintenance stage, 11, 105
and motivation, 59–61
Precontemplation stage, 10–11, 104–105
Preparation stage, 11, 105
processes by, 108f
questionnaire, example of, 12
Stimulus control, 11, 107t
Strength training, 208t, 216t
Subjective norm, 25
T
Tailored electronic print materials, 156
Teaching
components of, physical activities and exercise, 268f
240
and learning, 267
tips for, exercise, 267t
Telephone and electronic communications, 265, 267
Text messaging, 163, 166t
evidence, 164–165
limitations, 169–170
samples, 167t, 168t, 169t
Theories and models, importance of, 4–5
Theory of planned behavior (TPB), 16f
belief items, 26–27
evidence, 25, 27
examples of, 28–31
expected outcomes of PA, 84
Training
intermediate/advanced training, 138
introductory training, 138
Transtheoretical model (TTM) of behavior change, 80
Action stage, 11, 105
goal in, 117
Contemplation stage, 11, 105
goal in, 112
decisional balance, 11
evidence, 12
Maintenance stage, 11, 105
avoiding boredom, 121–123
goal in, 119
relapse prevention, 123–124
Precontemplation stage, 10–11, 104–105
goal in, 109
Preparation stage, 11, 105
goal in, 114
processes of change, 11–12
relapse prevention, 123–124
self-efficacy, 12
stages of change, 10–11, 10f, 104–105, 105f
Twitter, 171t, 173
links, 173
following on, 173
group, 175f
tweets, 154, 173
241
U
Urban design, definition of, 193t
V
Verbal and nonverbal communications, 264–265
Verbal persuasion, 5–6, 8, 87, 88
Vicarious experience, 5, 7–8, 87, 88
Vigorous (physical activity), 193t
Vigorous-intensity cardiorespiratory exercise, 40
Volitional maintenance self-efficacy, 63
W
Web-based intervention, 160
Web interface, 182–183
WebEx, 154
Y
Youth
adherence and maintenance considerations, 212–213, 212t
barriers, 212
evidence, 207
242

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ACSM’s

Claudio R. Nigg, PhD

Copyright © 2014 American College of Sports Medicine

Library of Congress Cataloging-in-Publication Data

Claudio R. Nigg, PhD

Adrian Bauman, MD, MPH, PhD

Ute Bültmann, PhD

Lauren Capozzi, BSc

Brian Cook, PhD

S. Nicole Culos-Reed, PhD

Danielle Symons Downs, PhD

Paul Estabrooks, PhD

Carol Ewing Garber, PhD, ACSM-PD, ACSM-RCEP, ACSM-HFS

Klaus Gebel, PhD

Eric Hekler, PhD

Sara Johnson, PhD

Kristina Kowalski, BSc, MSc, PhD(c)

Sonia Lippke, PhD

Rona Macniven, MSc, BSc

Greg Norman, PhD

Serena Parks, PhD

Heather Patrick, PhD

Kimberly Perez, MA, ACSM-HFS

Ken Resnicow, PhD

Ryan Rhodes, PhD

Pedro J. Teixeira, PhD

Claudia Voelcker-Rehage, PhD

Geoffrey Williams, MD, PhD

Sherry Barkley, PhD, ACSM-RCEP

Beth Bock, PhD

Cynthia M. Castro, PhD

Nickles I. Chittester, PhD

Joseph T. Ciccolo, PhD

Bhibha M. Das, PhD, MPH

Kelliann K. Davis, PhD, ACSM-CES

Rebecca Ellis, PhD

Christy Greenleaf, PhD, ACSM/NPAS-PAPHS

Katie M. Heinrich, PhD

Patricia J. Jordan, PhD

Mary Ann Kluge, PhD

Emily Mailey, PhD

Kathleen A. Martin Ginis, PhD

Kristen McAlexander, PhD

Melissa Moore, PhD

Charles F. Morgan, PhD

Terra Murray, PhD

Neville Owen, PhD

Ron Plotnikoff, PhD

Sarah Pomp, PhD

Deborah Riebe, PhD, FACSM, ACSM-HFS

David Seigneur, MS, ACSM-CES, FAACVPR

John C. Spence, PhD

Takemi Sugiyama, PhD

Sara Wilcox, PhD, FACSM

Catherine B. Woods, PhD

Julie A. Wright, PhD

CHAPTER 1 Why Do People Change Physical Activity Behavior?

CHAPTER 3 Building Skills to Promote Physical Activity

CHAPTER 4 Building Motivation: How Ready Are You?